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EC 221 343

Boros, Alexander, Ed.Alcohol and the Physically Impaired: SpecialFocus.

National Inst. on Alcohol Abuse and Alcoholism(DHRS), Rockville, Md.ADM-89-15189

101p.

Superintendent of Docments, Mail Stop: SSOM, U.S.Government Printing Office, Washington, DC 20402-9375($8.00 per year; $4.00 single copy).Collected Works Serials (022) ReportsDescriptive (141) -- Guides - Non-Classroom Use (055)Alcohol Health & Research World; v13 n2 1989

MF01/PC05 Plus Postage.*Alcohol Abuse; *Alcoholism; Blindness; CollegeStudents; Disease Incidence; Epilepsy; *rtioloTi;Higher Education; *Intervention; *PhysicalDisabilities; Physical Therapy; *Rehabilitation;Research Projects; Visual ImpairmentsArthritis; Head Injuries; Spinal Cord Injuries

The articles in this special issue explore theconnections between the dual disabilities of alcohol abuse andphysical impairment, and reflect progress made in exploring thecauses and treatments of alcohol abuse a,nrig the physically impaired.Selected articles include: "Results of a Model Intervention Programfor Physically Impaired Persons" (Sharon Schaschl and Dennis Straw);"Alcohol .'buse and Traumatic Brain Injury" (Gregory Jones); "AlcoholAbuse ano persons Who Are Plind: Treatment Considerations" (Michael

Nelipovich and Elmer Buss); "Treatment of Alcohol Abuse in Personswith Recent Spinal Cord Injuries" (Allen Heinemann et al.);"Intervention with Visually Impaired Children of Alcoholics"(Christine Saulnier); "Double Trouble: Alcohol and Other Drug Useamong Orthopedically Impaired College Students" (Dennis Moore andHarvey Siegal); "Arthritic Disease and Alcohol Abuse" (David Nashel);"Epilepsy, Seizures, and Alcohol" (Michael Stoll); "Alcohol and OtheiDrug Abuse by the Physically Impaired: A Challenge for RehabilitationEducators" (Bobby Groer); "Epidemiologic Bulletin No. 21:Alcohol-Related Morb,dity among the Disabled: The Medicare Experience1985" (Mary Dufour et al.); "Highlights from the 1987 National Drugand Alcoholism Treatment Unit Survey (NDATUS)" (Joan Harris and JamesColliver); and "A New Agenda for Alcohol Research: Tie Institute ofMedicine Reports on Causes and Consequences -A Summary." (JDD)

* * * * * * * * * * * * * * * * * * * * * * * * * * * ..{. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

* Reproductions supplied by EDRF are the best that can be made* from the original document.********************************************************,**************

NALNILlete,Aworm

RECEIVED JuL 0 1989Volume 13Number 21989

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Points of view or opinions stated in this docu-ment do not necessarily represent officialOERI position or policy

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AlcohollesellzhWorkl SPECIAL FOCUS

Alcohol- and the Physically Impaired

From the Editors

Facing the ChallengeALEXANDER BORGS

Alcohol Abuse and Traumatic Brain InjuryGREGORY A. JONES

99

101

104

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

Double Trouble: Alcohol and Other Drug Use 118Among Orthopedically Impaired College StudentsDENNIS MOORE AND HARVEY SIEGAL

Arthritic Disease and Alcohol Abuse 124DAVID J. NASHEL

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

Intervention with Visually Impaired Children of Alcoholics 132CHRISTINE SAULNIER

Epilepsy, Seizures, and AlcoholMICHAEL J. STOIL

138

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

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

PAGE III

PAGE 104

PAGE 118

97

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PAGE. 183

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

Epidemiologic Bulletin No. 21:Alcohol-Related Morbidity Among the Disabled: TheMedicare Experience 1985MARY C. DUFOUR. DARRYL BERTOLUCCI, CAROL COWELL.

FREDERICK S. STINSON, AND JOHN NOBLE

Readers' Exchange:Hearing-Impaired AlcoholicsAn UnderservedCommunityGLADYS A. KEARNS

Alcoholism and Bullous Changes of the LungsSIDNEY L. CRAMER

158

162

166

Departments:Occupational Arena: 'Keating Patients with 168Alcohol-Related TraumaA Report from the ARUSSymposium

International Perspectives: Alcohol-Related Trauma in 174M "cico

Special Populations: NIAAA Suppor, for Studies on 176Hispanic-Americans

Research Reports:Highlights from the 1987 National Drug and Alcoholism 178Treatment Unit Survey (NDATUS)JOAN R. HARRIS AND JAMES D. COLLIVER

A New Agenda for Alcohol Research: 183The Institute of Medicine Reports on Causesand ConsequencesA Summary

,

NI ALCOHOL HEALTH & RESEARCH WORLD

FROM THE EDITORSIn 1980, Alcohol Health & Re-search World presented an issuethat focused on persons with bothphysical impairments and alcohol-related problems. At that time,most research on physical impair-ment and alcohol abuse centered ondocumenting the relationship be-tween those two conditions. Muchprogress has been made since thenin exploring the causes and thetreatments of alcohol abuse amongthe physically impaired.

The articles in this issue reflectthis progress and explore the con-nections between the twat disabili-ties of alcohol abuse and physicalimpairment. Some of these connec-tions are subtlesuch as that be-tween alcohol abuse and arthritis,as described by Nashel, and thatbetween alcohol abuse and epilepsy,as described by Stoil. Other connec-tions are dramaticthe finding,expressed by Moore and Siegal,Jones, and Heinemann and co,

leagues, that alcohol abuse oftendevelops before physical impair-ment and that physical impairmentis the result of accidents related toalcohol abuse, is perhaps the mos'dramatic. These authors state thatif alcohol abuse was a problembefore physical impairment, it islikely to continue to be a problem.The need to address alcohol abusewhile treating the physically im-paired becomes crucial to patientrecovery.

At the same time, the psychologi-cal and practical problems of thephysically impaired must be ad-dressed in any number of settings ifalcoholism treatment is to succeed.Treatment centers, inpatient units,and self-help groups, in meeting thespecial needs of the physically im-paired, can be most effective inhelping their alcohol-dependentclients. Examples and practicalguidance to meet these needs areprovided in the articles by Saulnier,Schaschl and Straw, Jones, Neli-povich and Buss, and Heinemannand colleagues.

Many of the authors in this issuebelieve that current levels of exper-tise can be expanded through in-creased interaction between physicalrehabilitation specialists and theircolleagues in the field of alcoholismand other addiction treatment.Greer, for example, suggests thatthis type of interaction should bepart of the curriculum for trainingrehabilitation professionals. Saul-

t+

nier describes the important. ofthis interaction to an inpatient pro-gram for the visually impaired, andde Miranda and Cherry describehow shared interests and activismamong the two groups of profes-sionals have resulted in a statewideeffort in California.

One crucial factor remains un-changed when comparing 1980 to1989: the enthusiasm and dedica-tion of the inaividuals involved indiagnosing, treating, and preventingalcohol-related problems among thephysically impaired. The editors ofAlcohol Health & Research World,including Guest Editor AlexanderBoros, were delighted with the re-sponse to the development of thisissue of the journal. We hope thatsome of this enthusiasm is trans-mitted to the reader along with theresearch results, clinical observa-tions, and experience-based recom-mendations that comprise thisSpecial Focus issue.

VoL. 13, No.2, 1969 -99

&tout GORDIS, M.D., Director, NationalInstitute on Alcohol Abuse and AlcoholismKENNETH R. WARREN, PH.D., Director, Officeof Scientific Affairs, Nation, Institute onAlcohol Abuse and Alcoholism

CATE TIMMERMAN. EditorEve N. SHAPIRO, Managing EditorANN M. BRADLEY, Associate EditorJOHN J. DOR1A, Associate Editor

MICHAEL J. STOIL, PH D., Special FocusEditor

BEATRICE B. KF-SSLF.R. Copy Editor

MARY S. MOYNIHAN. Copy Editor

ALEXANDER M. TUCKER, An Director

MAURA GAFFNEY, Editorial Assistant

ABOUT THE COVER

The International Smbol of A< was

adopted in 1969 at Rehabilitation International's11th Woild Congress on Rehabilitation of theDisabled It is used throughout the world and itfunctions on two levels The symbol indicatesto persons who are physically impaired that abuilding or a facility iS accessible to them and.on a broader level, it IS an emblematic reminder

that while person, with physical impairmentsshould he recc,gnized as having Special needs

they ?.. e invoked in the same day-to-dal,

activities as are person, without SUlhimpairments

It IN hoped that the ,)mbol will continue tohe used to increase the awareness of the general

public of the problems that ideological and

architectural barriers present to ph) sicalkimpaired persons

100

EDITORIAL ADVISORY BOARD

THOMAS E BABOR, PH 0./UntVerSay ofConnecticut Hefoth Center/Department ofPsychiatry/Farmington, CTPETER BELL, B.A./Minnesota Institute onBlack Chemical Abuse/Minneapolis, MNHOWARD DIANE, PH D./Research Institute onAlcoholism/State University of New York/Buffala NYFuom E. BLOOM, M.D./Scripps Clinic andResearch Foundation/La Jolla, CAWILLIAM BurvNsKt. PH.D./National Associa-tion of State Alcoholism and Drug AbuseDirectors/Washington, DCRAUL CAETAND PH D./Medical Re-search Institute of San Francisco/Berkeley,CARICHARD A. DEITRIC H, PH D./University ofColorado School of Medicine/Denver, COJEROME A. HALLAN, DR.P.H./ Health areAdministration/Oregon State University/Corvallis, ORRICHARD JESSOR. PH.D. /University of Colo-rado Institute of Behavior Science/Boulder,COTHic-ILti LI, M.D./Indiana UniversitySchool of Medicine/Indianapolis, INCHARLES S. LIEBER, M.D. /Mt. Sinai Schoolof Medicine/ VA Medical Center/New York,NYJANE BENNER LORENZ, B.A./National Federa-

tion of Prents for Drug-Free Youth/Deerfield, ILALBERT B. LoweNens, M.D./New YorkMedical College/Westchester County Medi-cal Center/Valhalla, NYDONALD C. MARTIN, PH D./University ofWashington Department of Biostatistics/Seattle, WAELLEN R. MOREHOUSE. A.C.S.W./StudentAssistance Services/ White Plains, NYPAUL M. ROMAN, PH.D./University of Geergia Institute for Behavioral Research/Athens, GAROBERT J. SOKOL, M.D./ Wayne State Univer-

sity School of Medicine/ Hutzel Hospital/Detroit, MILAWRENCE WALL 4C K, DR .?.H./Untverstty ofCalifornia School of Public Health/PacificInstitute for Research and Evaluation/Berkeley, CAJOSEPH WESTERMEYER, M.D., PH D./University of Minnesota/Minneapolis. MNSHARON C. WILSNACK, PH D./ University ofNorth Dakota School of Medicine/GrandForks. ND

Alcohol Health & Research World(ISSN 0090-838X) is a quarterly produced

ozler contract by the National Institute onAlcohol Abuse and A', aholism (NIAAA).Terry Freeman is the Project Officer. TheSecretary of Health and Humaa Services hasdetermined that the publication of thisperiodical is necessary in the transaction ofthe public business required by law of thisDepartment. Use of funds for printing thisperiodical has been approved by the Directorof the Office of Management and Budgetthrough September 30, 1989. Opinionsexpressed in con:ributed articles do notnecessarily reflect the views of NIAAA. TheU.S. Government does not endorse or favorany specific commercial product or com-modity. Trade or proprietary names appear-ing in this publication are used only becausethey are considered essential in the contextof the studies reported herein.

Manuscripts concerning research, treat-ment, or prevents a of alcoholism andalcohol problems are solicited and should besent to the Editor, Alcohol Health & Re-search World, c/o CSR, Incorporated, Suite600, 1400 Eye Street, NW., Washington, DC20005. Electronic submission on 5 I/4-inchdiskettes is acceptable Unless otherwisenoted ii the text, all material appearing inthis magazine is in the public domain andmay be reproduced without permission.Citation of the source is apprt dated

Subscriptions and changes of addressshould be sent to the Superintendent ofDocuments, Mail Stop: SSOM, U.S. Gov-ernment Printing Office, Washington, DC20402-9375. Subscriptions are $8 per year or$10 if mailed to a foreign address Singlecopies arc isvallabie at $4 ($5 to a foreignaddress, These prices are subject to changewithout notice

ALCOHOL. HEALTH & RESEARCH WORLD

Buddy and Ruth from Incurably Iturnapta, (Temple University Press) © Bernard F Stehle. 1985

Facing the Challenge

The special winter 1980-1981 issue of AlcoholHealth & Research Worldused the tern~ "multidis-

ALEXANDER BOROS. PH D., is profes-sor of sociology at Kent State Uni-versity and founder and director ofthe Addiction Intervention with theDisabled Project. Dr. Boros servedas Guest Luritor of this SpecialFocus issue of Alcohol Health &Research World. Comr.ents on thisarticle should be addressed to theauthor at the Department of Soci-ology, Kent State University, Kent,Ohio 44242.

VoL. 13, Na 2, 1909

ALEXANDER BOROS, PH.D.

abled alcoholic" to refer to an alco-holic who had the additional dis-ability of a mental or physicalimpairment. That issue focused orrecognizing and treating the multi-disabled and announced a newdisability initiative by the NationalInstitute on Alcohol Abuse andAlcoholism (NIAAA). The treat-ment and prevention specialistswere expected to follow the exam-ples cited in those pioneeringarticles and to continue to ad-vance knowledge of this uniquepopulation.

The articles in this issue providenew insights into treating and un-

C.

derstanding problems of individualswith physical impairments andalcohol- or other drug-relatedproblems. These contributionsemphasize the importance of un-derstanding what makes thispopulation special. The legal andpsychosocial aspects of interventionamong people with physical impair-ments pose challenges to be facedby treatment and preventionspecialists.

The Rehabilitation Act of 1973,section 504 (Public I :.w 93-122),identifies a "handicapped" personas anyone with a physical or mentaldisability that limits substantiallyone or more of such major life

101

Facing the Challenge

activities as walking, seeing, hear-ing, speaking, working, or learning.Today, the terms "physically im-paired" and "disabled" are pre-ferred to the term "handicapped"that was employed in the 504 regu-lations. Physical impairments, ac-cording to section 504, may includeblindness, cancer, cerebral palsy,deafness or hearing impairment,diabetes, epilepsy, heart disease,multiple sclerosis, muscular dystro-phy, orthopedic impairment, per-ceptual impairments, and spinabifida. Mental or emotional illnessand mental retardation also aredescribed as impairments in thelegislation.

An estimated 16 percent of oursociety is physically or mentallyimpaired (Bowe 1978). According toKirshbaum (1979), clinical evidencereveals that the physically impaired

have a 20-percent rate of alcohol orother drug abusea rate twice ashigh as that among able-bodiedadults. Kirshbaum'F csiimate issupported by the findings of anarticle included in this issue, theEpidemiologic Bulletin No. 21.

Several authors represented inthis issue have documented that amajority of physically impairedindividuals with alcohol- or otherdrug-related problems appear toshow evidence of such problemsbefore the onset of impairment; alarge percentage of these individ-uals became physically impaired asa result of trauma that is caused byabuse of alcohol or other drugs. Aminority of physically impairedindividuals develop alcohol or otherdrug abuse following onset of im-pairment. A number of stressfulcirc:_mstances associated with dis-

abilities may contribute to continu-ation of alcohol or other drugabuse after an individual becomesphysically impaired (Boros 1983):

The physically impaired person ishandicapped in adjusting to asocial and material world de-signed for normal persons.Most home-bound persons withphysical impairments face bore-dom and a lack of challengingactivities.In addition to normal dailystress, physically impaired pc.-sons must cope with frustrationslinked to the impairment and, insome cases, with chronic pain.Many unemployed or underem-ployed persons with physical im-pairments lack adequate incomeor resources to pay for servicesthat they require.

BARRIERS TO ALCOHOLISM TREATMENTENCOUNTERED BY PERSONS WITH PHYSICAL IMPAIRMENTS

he following barriers to alga-1 ment for the disabled have

been reported in the literature(Boros 1983):

Programs for disabled alco-holics ere few and still color-atoti; standanlized maidthat can easily be indtated hasemerged.

'Vestment acftvitiel need to bepaced at a slower rate for clientswho require more time formobility andixernunicatina,inclu ding *is Who areblind, deaf, sintintellectuellyimpaked,Sometallitatallailities are notace**. talatiaOtit in wheel-chairs* hitlioieiho use othcaids In wi.lkinaThe prevalence of misplaced

sympathies among alcoholismcounselors is not conducive tothe necessary confrontation ofthe physically im paired client'sdenial of alcoholism.Police and courts often respondinappropriately to physicallyimpaired pet** arrested foralcohol- or other drug-relatedoffenses, sending them homerather than to treatment.ilea** Ind recovery facilitiesoften cannot provide transporta-tion for orthopedically impairedcliezrts.%Allies often may be less de-*siding of treatment for thepirssically linpaired rev a-berth* they would be for anatiobodial relative.Individnift with severe impair-ments frequently lack employ-ment and therefore lack

job-related incentives to seektreatment.The local community networkof alcohol and other drug abuseservice providers may be per-ceived as disjointed and inacces-sible by persons with physicalimpairments, particularly whensuch impairments impede nego-tiation of bureaucratic hurdlesto obtaining treatment.Professional literature fails toaddress adequately the uniquetreatment problems facing phys-ically impaired alcoholics.

The above 10 generalized barriersreflect experiences of those seek-ing treatment serves for alco-holics and other drug abusers.Such barriers vary significantlywithin each community.

-ALEXANDER BOROS. PH.D.

102 ALCOHOL HEALTH & RESEARCH WORLD

Persons with severe impairmentsoften have easy access to addic-tive prescription drugs. Too often,the physically impaired per-son mixes prescribed drugswith alcohol, resulting in direconsequences.Physically impaired persons facea double stigma for the impair-ment and for alcohol or otherdrug abuse. They often sensesocietal rejection when deprivedof jobs, recreation, and services.When physical impairment al-ready has made a person feel lessthan complete, admitting to alco-hol or other drug abuse often isanother blow to self-esteem.Persons with physical impairmentmay present strong rationaliza-tions for drinking. It is difficultto convince such individuals thatsobriety offers a rewarding a'iter-native to life's problems escapethrough use of alcohol or otherdrugs may appear to be satisfy-ing, at least in the short run.

These circumstances vary amongindividuals and types of impair-ment; nevertheless, their existencesupports the argument that personswith physical impairment are atrelatively high risk for alcohol orother drug dependence.

One of the challenges facingprofessionals in the addiction fieldis to understand why alcohol andother drug abusers with physicalimpairments tend to be under-treated. Some of the barriers toalcoholism treatment encounteredby persons with physical impair-ments are identified in the accom-panying sidebar and in articlesincluded in this issue. In general, areview of the literature shows thatalcohol and other drug abuse inter-vention programs are less accessibleto those with physical impairmentsthan they are to able-bodiedpersons.

Vol. 13, No. 2, 190

Progress in the field of alcoholand other drug abuse has occurredwithout much attention to theunique needs of persons with physi-cal impairments. The advent of theAlcoholics Anonymous self-helpprogram in 1935 gave sufferingalcoholics a boost in moralethrough peer group resources(Kurtz 1979), but not all AlcoholicsAnonymous or other self-helpgroups effectively respond to mobil-ity needs or communication needsof persons with physical impair-ments. Nearly 50 years ago, theCenter of Alcohol Studies and theQuarterly Journal of Studies onAlcohol were organized to promotethe development of a professionalbody of research-based knowledgeon alcoholism, and in 1949, profes-sionals interested in problems ofaddiction were brought together forthe first time with the creation ofthe North American Association ofAlcoholism Program (Strachan1971). Prior to the mid-1970s, how-ever, research literature rarely ad-dressed the problems of alcohol crother drug abusers who had con-comitant physical impairments, andprofessional associations in thealcohol research and treatmentfields offered minimal coverage ofphysical impairment-related con-cerns at annual and regionalmeetings.

Slowly, the condemnation ofalcoholism as a moral weakness hasbeen replaced with the growingacceptance of alcoholism as a dis-ease. The use of social therapies inthe treatment of alcoholic patientswas another breakthrough (Root1967). Government involvement infinancing and planning services foralcoholics provided needed re-sources to specialty populations(Hewlett 1967) and to the develop-ment of school-based preventionprograms. Persons with physicalimpairments have not benefited

fully from these gains achiesed inthe addiction field. With fc.v excep-tions, intensive inpatient treatmentprograms do not meet the needs ofphysically impaired clients. Further-more, prevention curriculums forspecial education departments touse in educating high-risk disabledyouth often receive priority forState funds earmarked for the en-tire physically impaired at-risk pop-ulation; adults with physicalimpairments and alcohol-relatedproblems rarely are targeted forspecial support by governmentagencies.

Great gains have been made inthe addiction field, but people withmajor life-limiting impairmentscontinue to be undertreated andundercounted. This special focusissue of Alcohol Health & ResearchWorld reminds us that the challengeof making treatment and preventionaccessible and responsive to peoplewith physical impairments is a chal-lenge that faces us all.

REFERENCES

SOROS, A Physically disabled alcoholics:The latest challenge In: Cleminshaw, H.K ,and "fruit, E B., eds. Alcoholism. NewPerspectives. Akron, OH: Center for UrbanStudies, 1983. pp 35-46.

BOWE, F Handicapping America: Barriers toDisabled People New York. Harper andRow, 1978.

HEWI Err. A.G Governmental responses toalcoholism in North America. In: Pittman,D J , ed. Alcoholism. New York: Harperand Row, 1967 pp 223-246.

KIRSHdAUM, H 15 to 3007o of 21,000 disabledin California area called abusers. Arise, May1979, p 38.

Kuirrz. E Not God. A History of AlcoholicsAnonymous. Hazelden, MN HazeldenEducation Services, 1979.

Roar, L.E Social therapies in the treatmentof alcoholics In. Pittman, D.J , ed. Alco-holism New York: Harper and Row, 1967.pp. 142-156.

STRAC HAN, G T Practical Alcoholism Pro-gramming. Vancouver, Canada- MitchellPress, 1971.

193

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GREGORY A. Jos

The role of alcohol andother drug abuse in trau-matic brain injury is welldocumented, with an inci-

dence of intoxication at injury ofapproximately 50 percent. Because ofcognitive, behavioral, and functionalc'eficits, brain injury survivors poseunique challenges to the alcoholismtreatment field.

HEAD INJURY AND ALCOHOL ABUSE

Alcohol consumption is a strongpredisposing actor in traumatic brainjury (Kerr et al. 1971; Field 1976;Parkinson et al. 1985). In studiesaddressing head injury and alcoholuse specifically, elevated blood alcohollevels were present in more than 40percent of the patients seen in emer-gency rooms or admitted to hospitalsbecause of traumatic head injury

GREGORY A JONES is in °gramdoe( for for ( helm( al health at theV Inland National Centel oi Lor etto,Mollie sofa

Richard Rush

(Galbraith et al. 1976; Rutherford1977; Brismar et al. 1983; Parkinsonet al. 1985). In the most recent studyof head-injured patients at a NorthAmerican trauma center, 67 percentof those tested for blood alcohol levelsshowed evidence of alcohol use andmore than one-half (51 percent) wereintoxicated, using a definition of 100mg/100 ml (100 mg/dl) (Sparadeoand Gill, in press). This is consistentwith a Swedish study showing a 58-percent rate of intoxication amongthose tested (Brismar et al. 1983).

In a study of neuropsychologicaldeficits in alcoholics, psychometrictest performance was significantlylower among head-injured alcoholicsthan among those who had not ape-rienced head injuries (Hillivm andHolm 1986). Both groups scoredlower than the general population onmost test items. Results of the studyalso suggest that the incidence of headinjury in alcoholics is two to fourtimes higher than in the generalpopulation.

Other studies have documented therole of alcohol and other drug abuse

*t , :

Brain Injury

in traumatic brain injury. Altermanand llarter (1985) found the risk forhead injury in patients with familialalcoholism to be almost twice that ofpatient: without such histor:,. In astudy of 75 severely brain-injuredpatients (Ibbis et al. 1982), 51 hadhistories of alcohol abuse and 29 hadhistories of illicit drug use. The num-ber of patients using both alcohol andother drugs was not specified. Spara-deo and Gill (i t press) found that 25percent of their sample had alcoholhistories documented in their medicalrecords. A recent Nrvey of braininjur, rehabilitation programs aroundthe country reported that approxi-mately 55 percent of patients hadsome alcohol or other drug abuseproblems before the brain injury and40 percent had abuse problems de-scribed as moderate to severe (NHIF1988).

PSYCHOSOCIAL CONSEQUENCES OF

HEAD INJURY

Traumatic brain injury can meanmany lcng -term psychological andbehavioral difficulties. Because everyMead injury is differelit, it is impos-sible to predict the exact outcome forthe survivor. While generalizations r utbe made, it is important that treat-ment professionals and other con-cerned persons note that individualsmay present few problems or a combi-nation of b..--veral problems. Somedeficits following head injury arepainfully obvious; others are ex-tremely subtle and become evidentonly during intensive clinical evalua-tion (Lezak 1978b). Alcohol ar.,, otherdrug abuse professionals working withhead :njury survivors commonly dealw;tht ctients who appear to functionnormally in most settings but who areunable to understand the concepts ofalcohol or other drug addiction or tobenefit from traditional treatmentmodalities.

lb work effectively with survivorsof traumatic injury, it is vital

106

Many brain injurysurvivors . . . aremore easily distractedby extraneous stimuliand have a reducedabilfty to concentrateand focus.

that alcohol and other drug abuseprofessionals acquaint themselves withthe unique problems these clientspresent. The following discussion of'he more common consequences ofnead injury is drawn from generalknowledge in the field of brain injuryrehabilitation. For more Detailed in-formation, the reader is directed toLevin arc' _olleagues (1982), Edelsteinand Couture (1984), Lezak (1978a,1978b, 1983), and Brooks (1984).

Impairment of memory Post-traumatic amnesia is one of the mostcommon consequees of head injury.For many survivors, memory forevents and conditions prior to theirinjury is generally intact w!ile short-term memory for recent everts isdisrupted. In practical terms, thismeans that brain injury survivorsmight remember the events of theirhigh school prom in great detail but"orget what was served for breakfastthis morning. Some survivors may tryto fill in the gaps with confabulation,a usually sincere attempt to maskmemory deficits that is sometimesmisinterpreted :is dishonesty. Impair-ment of recent memory makes it diffi-cult for many survivors to retaininformation and gentralize new learn-ing from one setting to another.

Decreased self - awareness andinsightMany survivors of traumaticbrain injury experience a reducedcapacity for insight, self-monitoring,and awareness. They may have diffi-

I

culty seeing the relationship betweentheir behavior and the resulting conse-quences and may experience confu-sion or frustration in their attempt tounderstand situations.

Impairment of abstract reasoningThe ability to integrate informationand to reason ir tv abstract are vitalskills in our "information age." Un-fortunately, many brain injury survi-vors experience a reduction in theseskills and a corresponding increase inconcrete thought. In assessment, theseproblems are sometimes detected inproverb interpretation tasks, whereclients may be unable to move be andthe concrete content of a simple say-ing to its more abstract meaning(Lezak 1983).

Deficits of attention and concen-trationMany brain injury survivorshave difficulty attending to complextasks. They are more easily distractedby extraneous stimuli and have areduced ability to concentrate andfocus.

Inappropriate social behaviorProblems with impulsiveness anddisinhibition are common amongsurvivors of traumatic brain injury.They may giggle or make inappro-priate comments; they may interact ina rude or aggressive man, T. Excessiveflirting or more overt sexual gesturesare sometimes observed. Some survi-vors become withdrawn and isolated;others demon ra. behavior that isself-centered and perceived as imma-ture. They may have a low tolerancefor stress and be easily frustrated.

Changes :n mood and affectSomebrain injury survivors experiencec' anges in emotional responses. Af-rect may T.. some flat or blunted withlittle expression of either joy or sad-ness. Emotions may become labile,with broad swings of mood. Anger,along with feelings of profound grief,may be accompanied by a clinicaldepression.

Language and communicationdeficitsDamage to the brain may

ALCOHOL HEALTH & RESEARCH WORLD

result in oral-motor problems, such asslurring of speech and difficulty form-ing words (dysarthria). Of a moreserious nature are deficits of compre-hension or language disorders knownas aphasia. The brain injury survivormay not understand everything heardand may not be able to find the wordsor formulate the sentences necessaryto respond. These problems mayresult in increased frustration or confusion for survivors and concernedpersons alike.

Sensory deficitsThere is a highincidence of visual-perceptual prob-lems following head injury; readingand writing abilities may be impaired.Tinnitus (ringing in the ears) or otherdisorders may affect hearing.

Goal-fotmulation and problem-solving di/fiat/tiesUnrealistic orundefined goals are common amongbrain injury survivors. When they dohave clear and reasonable objectives,many survivors have a reduced abilityto solve problems and to achieve theirgoals without sufficient structure andsupport.

Voaltionalleducational problemsBecause of the permanence of braindamage and the long-term nature ofits consequences, few head ink-rysurvivors are able to return to theirpremorbud (prcinjury) level of voca-tional educational placement.Those who have survived mild injuriesoften retain the cognitive skills neces-sary to return to work but may experi-ence reduced tolerance for stress andincreased fatigue.

'piped on the family and commu-nityThe functional impairmentsfrom traumatic brain injury, thoughserious, do not usually require thatsurvivor., be institutionalized. In theirstudy of severely brain-injured pa-tients, -MIAs and colleagues (1982)reported that 72 percent had beerdischarged to return home; the rate ofcommunity discharge is even higheramong survivors of m....ierate andmild injuries. As a result, families

VoL. 13, Na 2, 1N9

and communities must face the issueof the reintegration of survivorswho may have experienced pro-found changes their abilities andpersonalities.

There is a high incidence of divorcefollowing head injury. Reports ofdepression and somatic disordersamong spouses or children of survi-vors are common. Many survivorsexperience social_ isolation andmarginalization a result of theirinjuriev; peer relationships and sup-port systems are often radicallyaltered.

ALCOHOL AND OTHER DRUG ABUSE

FOLLOWING HEAD INJURY

Vv nen the complex variable of alcoholor other drug abuse is consideredwithin the context of the social reinte-gration of brain injury survivors, thepotential for serious problems seemsclear. Given that the population as awhole has a high rate of documentedalcohol abuse prior to injury (andthat alcohol abuse is a key factor in

Psychosocialand functionalconsequences of braininjury complicate thealready difficult tasksof evaluation andtreatment.the etiology of brain injury), it isreasonable to suggest that alcoholconsumption following injury wouldalso be a problem. This is especiallyso, considering that the great majorityof brain injury survivors are dis-charged into the community, wherealcohol and other drugs are readilyaccessible. Reilly and colleagues (1986)have identified four factors that in-crease the risk of alcohol abuse aftertraumatic injury: 1) increased discre-

tionary time and boredom, 2) in-crewed enabling from family andfriends, 3) uncertainty over the abilityto return to work or to funcLan effec-tively at work, and 4) physical limita-tions and posttraumatic moodchange. All of these factors can befound among most brain injurysurvivors.

While anecdotal reports are numer-ous, there are few data on the inci-dence of alcohol and other drugabuse after brain injury. In one of thefirst attempts to document postinjuryuse patterns, Sparadeo and Gill (1988)found that 54 percent of the survivorsthey surveyed had returned to alcoholuse after completion of rehabilitation.This was in spite of the fact that themajority had been injured in motorvehicle accidents while under theinfluence of alcohol or other drugs.The two major factors influencingabstinence in the remaining 46 percentwere the presence of a seizure disorderor placement in long-term, supervisedliving situations.

CLINICAL CONSIDERATIONS FOR ALCOHOL

AND OITIER DRUG ABUSE PROFESSIONALS

Brain injury survivors present uniqueproblems for counselors and otherprofessionals because the psychosocialand functional consequences of braininjury complicate the already difficulttasks of evaluation and treatment.Given what is known about traumaticbrain injury and alcohol abuse, it islikely that most professionals willoccasionally encounter brain injurysurvivors; those practicing in urbanareas or among minority populationsshould give special attention to theincidence and consequences of braininjury. Cognitive and neurobehavioralproblems may have an impact on thefollowing areas of practice:

Assessment and diagnosisMemo-ry deficits tend to make brain injurysurvivors poor historians, and subjec-tive reports of alcohol or other druguse patterns may be inaccurate. Im-

107

Brain Injury

paired insight may keep survivorsfrom recognizing that their use pat-terns are problematic. Because manymild head injuries go unreported(Hil lbom and Holm 1986), it is rec-ommended that evaluators inquireabout previous accidents or injuries.A simple question such as "Have youever been knocked unconscious?"may be helpful in a preliminaryscreening for possible head injurystatus.

Because brain injury survivorssometimes have difficulty with ab-stract thought and more complexconcepts, brig or complicated assess-ment tool: may be ineffective. Con-sideration should be given to the useof a brief diagnostic tool such as theCAGE Questionnaire (Ewing 1984).Utilization of data from neuropsycho-logical or rehabilitation evaluations isalso suggested.

Changes in functional abilities areoften the most reliable and measur-able symptoms of alcohol or otherdrug abuse by head injury survivors.Once the practitioner has determinedthat such changes are not the result ofother medical conditions and can beassociated with known incidents ofconsumption, decreasing skills orincreasing patterns of maladaptivebehavior may provide observablediagnostic criteria for alcohol abuse.For the survivor, these declines infunctional ability can be devastating,limiting involvement in rehabilitationor vocational programming. Threaten-ing to discontinue essential servicesmay motivate the Drain injury survi-vor to respond to intervention.

Intervention and treatmentInsight-oriented approaches are prevalentamong treatment models for alcoholand other drug abuse (Logan et al.1987). However, the usefulness ofpsychodynamic approaches with braininjury survivors is questionable be-cause of the high incidence of cogni-tive deficits, such as impaired abstractreasoning and decreased insight. Be-

Effective casemanagement usuallyrequires aninterdisciplinaryapproach.

havioral difficulties of survivors, suchas impulsiveness and disinhibition,may cause conflict or tension in groupsessions, reducing the effectiveness ofthe sessions. Rather than receivingsupport and affirmation from groupmembers, brain injury survivors maybe stigmatized or characterized asdisruptive. These problems also maybe experienced in meetings of self-help groups, such as AlcoholicsAnonymous, where significant neuro-behavioral problems attributable tohead injury may be viewed as "char-acter defects."

In the case of brain injury rehabili-tation, the prevailing behavioral modelof intervention relies on achievingpositive long-term outcomes througha series of short-term goals (Goldsteinand Ruthven 1983; Wood 1987). Thisapproach may h.: more effective withinpatients than with alcohol- or otherdrug-abusing outpatients who live incommunity settings where factorsinfluencing behavior cannot be aseasily monitored.

In a manual examining methods ofcounseling head injury survivors inthe community, Blanchard (1984)emphasizes the need for practitionersto understand the cognitive and be-havioral consequences of head injuryand to rely more on such basic coun-seling techniques as respect, authentic-ity, and empathy.

Case managementAgencies andindividual practitioners serving braininjury survivors who abuse alcohol orother drugs are responsible for ad-dressing their often complex needs

and either providing necessary servicesor mat ing appropriate referrals. Ef-fective case management usually re-quires an interdisciplinary approachinvolving social workers, psycholo-gists, occupational and physical thera-pists, vocational counselors, andspecialists in community reentry. Pro-fessionals must acquaint themselveswith available programs, since refer-rals to economic or housing assistanceprograms and consultation with medi-cal or public health professionals maybe necessary. Services for spouses orfamilies of clients also should be con-sidered, because the dual problems ofdisability and alcohol or other drugabuse put intense pressure on familysystems.

Ftriurte Mammon's

The outlook for future developmentin the area of alcohol or other drugabuse and brain injury is mixed buthopeful. There remains a troublingavoidance of the problem on the partof clinicians who provide acute care tobrain injured persons. In a recent andquite revealing survey of 154 traumacenters in 43 States, only 55.2 percentregularly measured blood alcohollevels upon admission (Soderstromand Cowley 1987). In a retrospectivechart review of 379 trauma patientsseen in the emergency room of anurban teaching hospital, Chang andAstrachan (1987) found that al-though 43 patients were suspected orknown to have used alcohol or otherdrugs, none was referred for furtherevaluation.

Rehabilitation providers, on theother hand, have responded to theproblem of alcohol abuse and braininjury with a positive initiative. In1987, the Prof ssional Council of theNational Head Injury Foundationconvened a Substance Abuse TaskForce. The work of this group,though preliminary, has helped todefine the problem from both anetiological and clinical perspective andto suggest potential solutions. A posi-

ALCOHOL HEALTH & RESEARCH WORLD

tive finding of the task force is that 50percent of acute and 83 percent of thepostacute rehabilitation programssurveyed are addressing alcohol andother drug abuse within their range ofservices (NHIF 1988).

Better identification and interven-tion strategies for those with trau-matic brain injury will succeed only ifa corresponding initiative is under-taken within the alcohol and otherdrug abuse treatment field. Recom-mendations for development of effec-tive services for brain injury survivorsinclude improvement in the followingareas:

Research The number of braininjury survivors being served withinthe cunt. alcohol and other drugabuse treatment system is not docu-mented. Tb determine the effective-ness of current programs andmethods, it is essential that this popu-lation be profiled. While it may bereasonable to suppose that brain-injured persons who abuse alcohol orother drugs have a high incidence ofdischarge from treatment centers forfailure to meet treatment goals andale more prone to relapse than thosewithout brain injuri, this has notbeen established.

EducationPerhaps the greatestbarrier to the effective identificationand treatment of brain injury survi-vors with alcohol or other dryg abuseproblems is the continued lack ofawareness among professionals. Medi-cal and rehabilitation professiorlswould benefit from additional trainingin assessing alcohol and other drugabuse. Professionals treating clientswho abuse alcohol and other drugsneed more information about braininjury and its consequences. Alcoholand other drug abuse counselorsshould be encouraged to familiarizethemselves with the brain injury reha-bilitation programs and services intheir communities.

Interdisdplinary dialogue andcooperation Communication be-tween the rehabilitation and alcohol

and other drug abuse fields meritsfurther development, especially wherebrain injury is concerned. Pn.fession-aLs L-1 both fields have much to learnfrom each other.

Preliminary attempts to examineand integrate information from vari-ous fields have contributed much tothe effort. With additional research,education, and improved interdiscipli-nary cooperation, the outlook ishopeful.

The author thanks banns R. Sparadea Ph.D.,for generously prowling information and manu-script matenal necessary to the complenon of thisarticle.

REFERENCIN

ALTERMAN, A.I , AND TARTER, R.E. Relationship

between familial alcoholism and head injury.Journal of Studies on Akohoi 46(3)256-25F,1985.

BLANC-HARD, M.K. Counseling Head Irulaud

Patients. Albany, NY: New York State HeadInjury Association, 1984.

Pr ISMAR, B.; ENGSTROM, A.; AND RYDBERG, U

Head injury and mtoidcauon: A diagnostic andtherapeutic dilemma. Acta Ciunirjra Sam-dinavica 149:11-14, 1983

BROOKS, N. Closed Head lrywy: Psychological,Social and Family Consequenms Oxford. OxfordUniversity Press, 1984.

CHANG, G., AND AsrawcitAr.. B Identificationand disposition of trauma prtients with sub-stance abuse or psycluamc illness. ConnecticutMedicine 51:4-6, 1987.

EDEISTEIN, BA., Awn COUTUKE, E.D Behavioral

Ass.sprient and Rehabilitation of the Traumati-cally Elnim-Damagecl. New York: Plenum Press,1984.

EWING, J.A. Detecting akoholiso: the CAGEquestionnaire. Journal of the ,,imerican MedicalAssociat,on 252(14):1. J5-1907, 1984.

FIELD, J H. Epidemiology of Head injury inEngland and Wales: With Fttrticular Applicationto Rehabilitation. Leicester; Printed for H.M.Stationary Office by Willson, 1976.

GALBRAITH, S.; MURRAY, W R ; PATE' , A.R.; AND

KN`IAJONF_S, R. The Midair:ship between alco-

hol and head injury and its effect on the con-scious level. Bntish Journal of Surgery63:128 - 130,1976.

GOLDSTEIN. G., AND RtJVHVEN, L Rehabilitation

of the Bruin-Damaged Adult. New York: PlenumPress, 1983.

Va.. 13, No. 2,1199

HILLBOM. M., AND HOLM, L. Contribuucn of

traumatic head injury to neuropsychologicaldeficits in alcoholics. Journal of Neurology,Newtsurgery, and Psycluatry 49 1348-1353,1986.

KLRR, TA.; KAY, D.WK.; AND LASMAN, L.P.

Charactenstics of patients, type of accident andmortality in a consecutive series of head injuriesadmitted to a neurosurgical unit. Bnnsh Journalof Preventive and Social Medicine 25:179-185,1971.

LEVIN, H.S ; BENIGN, A.L.; AND GitossmArc

R.G. Neurobehavioral Consequences of ClosedHead Injury. New York: Oxford UniversityPress, 1982.

LEZAK, M D. Living with the characterologically

altered brain mjured patient. Journal of ClinicalPsychiatry 39:592- 598,1978a

LEZAK, M.D. Subtle sequelae of brain damage:perplexity, distractibility and fatigue. AmencanJournal of Physical Medicine 57(1):9-15, 19786.

LT ZAK, M.D. Neuropsycho/ogica/ Assessment.2nd ed. New York: Oxford University Press,1983.

LOGAN. S L ; McRov, R.G.; AND FREEmAN, E.M

Current practice approaches for treating thealcoholic client. Health and Social Won(12(3):178 -186, 1987.

National Head Injury Foundation. ProfessionalCouncil Substance Abuse "Risk Force. WhiteAmer. Southborough, MA: NHIF, 1988.

PARKINSON, D.; STEPHENSEN, S.; AND PHILLIPS, S

Head injuries. A prospective, computerizedstudy. Canadian Journal of Surgery 28(1).79-83,1985.

RIR I Y. E.L.; KELLEY, IT.; AND FA1LLACE, L.A.

Role of alcohol use and abuse in trauma. Ad-vances in Psychasomatic Medicine 16.17-3..1986.

RUTHERFORD, W. DlagTIOSIe sf alcohol ingestion

in mild 1.ead injuries. Lance. 1:1021, 1977.

Soneasntom, CA., AND COWLEY. R.A Anational alcohol and trauma center survey.Archives of Surgery 122(9).1067-1071, 1987.

SPARADEa ER., AND GILL, D. "Alcohol Use

After Head Injury." Paper presented at theannual conference of the Amencan Psychologi-cal Association, Atlanta, GA, August 1988.

SPARADECX F.R., AND GILL. D. Effects of alcohol

use on head injury recovery. Journal of HeadAmmo Rehabihtation (in press).

TOBIS, J.S.; PURI. K.B ; AND SHERIDAN. J. Reha-

bilitation of the severely brain - injured patientScandinawan Journal of Rehabilitation Medicine14(2):83-88, 1982

WOOD, R.L. Bruin limey Rehabilitation: ANeurobehavioral Approach. Rockville, MD:Aspen Publishers, 1987.

109

Treatment ofAlcohol Abuse inPersons with RecentSpinal Cord InjuriesALLEN W. HEINEMANN, PH.D.,MATTHEW DOLL, AND

SIDNEY SCHNOLL, M.D., Ph.D.

"Range-of-motion" exercises prescribed inthe early stages of rehabilitation allowpersons with recent spinal cord injuries tomaintain flexibility and strength and tomake maximum use of residual musclefunction

The prevalence of alcohol-related problems in per-sons with physicaldisabilities has emerged

as an issue in medicine and physicalrehabilitation. Physicians, rehabili-tation specialists, and service pro-viders increasingly are aware thatalcohol abuse not only can contrib-ute to onset of disability, but also

r

can undermine the rehabilitationprocess by impairing the learningprocess and increasing morbidity.

In patients whose disabilities arethe result of traumatic injury, theseeffects may be exacerbated. In onestudy, O'Donnell and colleagues(1981-1982) reported a 68-percentrate of alcohol or other drug use atthe time of a disabling spinal cordinjury (SCI) among 54 patients ona spinal cord injury unit; 68 percentof patients also resumed drinkingduring hospitalization Other re-searchers have found that the rateof intoxication varies between 17

4s

and 49 percent for persons whoincur traumatic injury (Galbraith etal. 1976; Fullerton et al. 1981; Galeet al. 1983; Frisbie and Tim 1984;Heinemann et al. in press). Im-paired judgment resulting fromintoxication appears to have beenresponsible for increased risk-takingthe cause of many of theseinjuries.

The prevalence of alcohol useand abuse following initial care fortraumatic disability also has beenreported in several recent studies. Ina 1985 study of vocational rehabili-tation and independent living centerclients with SCI, the rate of moder-ate and heavy drinking reportedwas 46 percent, nearly twice therate reported in the general popula-tion (Johnson 1985). The rate of

ALLEN W HEINEMANN, PH D., isdirector of the rehabilitation serv-ices evaluation unit at the Rehabili-tation Institute of Chicago, 448East Ontario Street, Suite 650,Chicago, Il/'nois 60611, and associ-ate professor in the Department ofRehabilitation Medicine at North-western University Medical School.MATTHEW DOLL, a graduate studentin psychology at Illinois Institute ofTechnology, assisted on the projectdescribed in this article. SIDNEYSCHNOLL. M.D., is chairman of thedivision of substance abuse in theMedical College of Virginia (Rich-mond) and president of the Associ-ation for Medical Education andResearch on Substance Abuse(AMERSA).

Alcohol Abuse Tteatment and SCI

alcoholic symptomatology has beenobserved to vary from 49 percent ofpersons with recent onset SCI(Heinemann et al. 1988a) to 62percent of vocational rehabilitationfacility clients (Rasmussen andDe Boer 1980-1981).

Although there are reports on thenature and extent of alcohol abuseamong traumatic injury patients,less information is available abouttraumatic injury patients who rec-ognize and seek treatment foralcohol-related problems. Knowl-edge of the factors leading to recog-nition and treatment for thesepatients should enable rehabilita-tion professionals to assist otherpatients in need of similar services.If, as Marlatt and colleagues (1988)suggest, personal injury contributesto a drinker's awareness of analcohol-related problem, then theperiod following injury may be aparticularly productive point atwhich to intervene.

In fact, failure to intervene canthreaten the entire rehabilitativeprocess. Unrecognized alcoholabuse may contribute to neglect ofself-care and, consequently, to in-creased morbidity. Psychologicaland social adjustmentsformida-ble enough already for persons whoincur traumatic injurymay becomplicated further by alcoholabuse. Continuation or resumptionof drinking following personalinjury also may interfere with pro-ductive physical activity by a reha-bilitation client (Heinemann et al.,in press). For these and other rea-sons, it is critical that rehabilitationprofessionals understand and,where necessary, facilitate the iden-tification and treatment of alcoholabusing clients.

THE REHABILITATION INSTITUTE OF

CHICAGO STUDY

The need to improve understandingof the behaviors associated with theperceived need for alcoholism

112

treatment among persons whoincur traumatic injury resulted inNIAAA-supported research at theRehabilitation Institute of Chicago,a 176-bed, nonprofit hospital in theMidwest Regional Spinal CordInjury Care System. The goal ofthe study was to describe the extentto which persons who had incurredtraumatic injuries experiencedalcohol-related problems, recog-nized they had problems, and thenacted to reduce abusive drinking.The objectives of the study were toassess the rate of alcohol use, prob-lems resulting from drinking, per-ceived need for treatment, andactual receipt of treatment for alco-hol abuse from 6 months prior to18 months after spinal cord injury.

A total of 168 patients admittedconsecutively met inclusion criteriafor this study,. Patients in the sam-ple were between 13 and 65 years ofage, cognitively intact, injured dur-ing the past 12 months, and Englishspeaking. Of the 154 patients forwhom physician permission to par-ticipate was obtained (90 percent ofeligible patients), 103 agreed toparticipate. The participant andnonparticipant groups did not dif-fer in age, gender, race, injury etiol-ogy, self-reported intoxication atinjury onset, marital or social sta-tus, diagnosis, or exposure to sub-stances for which routine toxicologyscreening was completed (Heine-mann et ai. 1988b).

Because approximately 1 monthis needed for patients to adjust to arehabilitation hospital eliv;ionmentand to consider favorably a requestto participate in a research project,patients were not approached aboutthis study until between 4 and 6weeks after admission. Patientswere told at the initial approachthat the security of their datawould be safeguarded by a confi-dentiality certificate and that theywere being asked to participate inthree interviews for which tliex

JL t /

...

would be paid $20 each. The firstinterview, conducted during inpa-tient rehabilitation, reviewed drink-ing patterns during the 6 monthsprior to injury. The second inter-view was conducted 6 months afterSCI, and the third interview oc-curred 18 months after SCI. Inter-views typically lasted 3 hours.

Of the 103 participants, 75 con-tinued through the third assess-ment. They ranged in age from 16to 63 years, with an average age of28.2 years. Men comprised 75 per-cent of the sample. Most of theparticipants were white (75 per-cent); the others were black (15percent), Hispanic (9 percent), andAsian (1 percent). The marital sta-tus of participants included thosenever married (63 percent), married(26 percent), divorced (8 percent),and separated (4 percent). Educa-tion attained included less thanhigh school graduation (28 per-cent), high school graduation orequivalent (59 percent), collegegraduation (7 percent), and gradu-ate degree completion (7 percent).The most frequent cause of injurywas a road or traffic accident (41percent), and quadriplegia was theresulting disability for 64 percent ofthe sample.

THE TYPE A DRINKER AS THE MODAL

ALCOHOLIC SCI PATIENT

A typology devised by Glass (1980-1981) highlights the potential dif-ferences between persons withphysical disabilities whose drinkingproblems predate injury (Type Adrinkers) and those whose drinkingproblems began after injury (TypeB drinkers). Glass asserted thatType B drinkers were more likelythan 'type A drinkers to have favor-able rehabilitation outcomes.

Applying Glass' typology to theChicago sample, 65 percent of thesample were classified as Type Adr nkers, with onset of drinkingproblems before injury. Six percent

ALCOHOL HEALTH & RESEARCH WORLD

were Type B drinkers, with onset ofdrinking problems after injury. Theremainder (29 percent) reported nodrinking problems during any timereriod. Drinker type was stronglyrelated to self-reported intoxicationat injury onset.

As expected, pre-injt.ry drinkingpatterns were strongly related tointoxication at injury. While theoverall rate of intoxication was 43percent, 27 of the 49 Type A drink-ers (55 percent), 1 of the 4 Type Bdrinkers (25 percent), and 3 of the20 nonproblem drinkers (15 per-cent) reported intoxicatiol at injuryonset. Type A drinkers also re-ported drinking and experiencingalcohol-related problems at moreassessment periods than did Type Band nonproblem drinkers. For ex-ample, 55 percent of the Type Adrinkers reported drinking on threeor more occasions at each of theassessment periods, whereas only25 percent of the Type B drinkersand 27 percent of the nonproblemdrinkers reported this pattern ofdrinking. Although this relation-ship was statistically significant, thesmall number of Type B drinkerslimits the generalizability of theseresults.

Relationships between demo-graphic variables and drinker typealso were examined. No relation-ship was found between drinkertype and age, injury etiology, levelof injury, race, marital status, ordrinking frequency and quantityimmediately after injury. Seventy-one percent of the men and 47 per-cent of the women were Type Adrinkers who reported significantlygreater drinking frequency beforeinjury than either Type B or non-problem drinkers. Both Type A andType B drinkers reported greaterdrinking frequency during the 6- to18-month postinjury period thandid nonproblem drinkers.

No differences were found be-tween participants who continued

VoL. 13, Na 2, 90

Pre-injury drinkingpatterns were stronglyrelated to intoxicationat injury.

through to the third interview andthose who dropped out of the studyin terms of age, sex, race, maritalstatus, injury etiology, quantity andfrequency of drinking before injury,number of alcohol-related prob-lems, perceived need for treatment,or receipt of treatment beforeinjury. However, noncontinuingparticipants averaged less for-mal education than continuingparticipants.

ALCOHOL CONSUMPTION PATTERNS

AMONG SCI PATIENTS

Alcohol consumption was quanti-fied by asking participants to reportthe frequency and quantity of alco-hol consumed during each of threetime periods: 6 months before in-jury, 6 months after injury, andfrom 7 to 18 months after injury.Quantity was coded as number ofdrinks per drinking occasion; fre-quency was coded on an 8-pointscale of 0 (no drinking) to 7 (bingedrinking). This measure quantifiesdrinking in a manner similar toseveral valid and reliable measures,including the Drinking Classifica-tion Indices (Brandsma et al. 1980),the Quantity-Frequency-VariabilityIndex (Cahalan et al. 1969), and theNational Alcohol Program Infor-mation System (NAPIS) ATC Cli-ent Intake Form (NIAAA 1979).

Because the reliability and valid-ity of self-report measures used toassess drinking and resultant prob-lems have been questioned, severalmethods were employed to substan-tiate the self-reports. lbst-retestreliability of substance use informa-tion for this sample typicallyexceeded 0.90 and, as reported

t

previously (Heinemann et al., inpress), evidence of valid self-reportswas obtained. Serum ethanol analy-sis conducted at patient's admissionto the acute SCI unit was in agree-ment with self-report in 78 percentof cases. Consumption withoutintoxication or intoxication withsome other substance, as well asinvalid self-report, could accountfor less than perfect agreementbetween these measures.

The proportion of the samplethat reported drinking on three ormore occasions during any of thethree assessment periods was 93percent. The proportion of thesample that drank on three or moreoccasions during the 6 months be-fore injury was 91 percent. Thatproportion dropped to 53 percentfor the 6 months after injury andincreased to 67 percent during thenext 12-month period (see Figure1). Median frequency of drinkingfor those who drank was three tosix times per week before injuryand one to two times per week atthe second and third assessments.Median quantity of alcohol wasfive drinks per drinking occasionduring the 6 months before injuryand four drinks per drinking occa-sion during the two postinjury as-sessment periods (see Figure 2).

Overall, the proportion of drink-ers declined from pre- to postinjury.However, fully two-thirds of thesample were drinking 18 monthsafter injury. Median consumptionalso declined from pre- to postin-jury, a finding consistent with theresults of Frisbie and Tim (1984).Nonetheless, a median of fourdrinks one to two times each weekwas observed 18 months afterinjury.

ALCOHOL-RELATED PROBLEMS AND

PERCEIVED NEED FOR TREATMENT

Seventy-one percent of the samplereported one or more alcohol-related problems, and 15 percent

113

Alcohol Abuse Reaanent and SCI

reported believing they neededtreatment for these problems.Eleven percent reported receivingtreatment.

Alcohol-related problems wereassessed by asking participants inthe Chicago study to report if theyhad experienced any of the follow-ing as a result of drinking: 1) lossof control over amount or strengthof alcohol used; 2) problems withfamily; 3) problems with friends;4) problems thinking, remembering,or controlling thoughts; 5) prob-lems at work; 6) physical or healthproblems; 7) becoming overly tired;8) becoming overly excited, agi-tated, or nervous; 9) experiencingnegative moods, such as sadness,depression, helplessness, or guilt;10) sexual problems; 11) r.-Auceddriving ability; 12) hallucinations;or 13) financial problems. Re-sponses to each of these categorieswere coded as 0 (no) or I (yes).Positive responses were summed toform an index of alcohol-relatedproblems similar to indexes formu-lated by Donovan et al. (1983) ant+Fillmore (1974).

Figure 3 shows the proportion ofthe sample reporting each of 13assessed alcohol-related problems ateach assessment period. The pro-portion of the sample reporting oneor more problems was 65 percentduring the 6 months before injury;this rate dropped to 17 percent dur-ing the 6 months after injury androse to 24 percent during the fol-lowing year. Pre-injury alcohol-related problems reported by atleast one-quarter of the sampleincluded loss of control over theamount used (32 percent), cognitivedifficulties (33 percent), fatigue (35percent), and driving problems (33percent). Relatively few personsreported any of these specific prob-lems after injury.

The rate of self-reported drinkingproblems also declined initiallyafter injury but increased to 24

114

Figure 1 Makin Pripianny7/ WI Patients Prior to Wur s MonthsPandidry, and la fsizolles PestIsenry40

ROM

percent at the last assessment. On-set of drinking problems was re-ported to be most common beforeinjury; only 6 percent reporteddrinking problems for the first timeafter injury. As might be expected,persons who acknowledged alcohol-related problems prior to injurywere far more likely to report beingintoxicated at injury onset thanwere persons with postinjury onsetof alcohol-related problems or noproblerto.

Perceiv:d need for treatment wasassessed by asking participants,

AIL

"During this time period, did youever think that you needed helpregarding use of this substance?"Similarly, receipt of treatment wasassessed by asking, "During thistime period, did you ever receiveany counseling of treatment foryour use of this substance?" Intoxi-cation at injury onset was assessedby asking, "Were you under theinfluence of alcohol or any otherdrugs at the time of your injury?"Findings at each assessment periodare shown in Figure 4.

The proportion of participants

41_ _4 ALCOHOL HEALTH & RESEARCH WORLD

who believed they needed assistance clined from 13 percent during thefor drinking-related problems de- immediate pre-injury period to 4

percent immediately after injury, tonone during the following year. Asimilar pattern was observed foractual receipt of assistance fordrinking problems: 7 percent re-ported receiving assistance beforeinjury; 3 percent reported receivingassistance immediately after injury;and 1 percent reported receivingassistance during the followingyear.

Persons who thought they neededassistance but did not receive treat-ment were asked why they did notseek assistance. At the first assess-ment, changing one's mind wascited by six persons. Other reasonscited included inability to affordtreatment (N.1), not knowingwhere to obtain treatment (N = 1),believing treatment was unavailable(N= 1), and believing that one'sdrinking pattern was unchangeable(N = 1). No reasons were given bypersons not receiving treatment atlater assessment periods.

SCI PATIENTS RECEIVING TREATMENT

FOR ALCOHOL-RELATED PROBLIMS

Participants receiving treatmentwere asked the most importantreason for their seeking treatment.At the first assessment, their rea-sons included employer referral(N.2), referral by family (N.1),and court-ordered referral (N.1).At the second assessment, one per-son each cited physician referraland a desire to sty drinking as thereason for seeking treatment. Oneperson at the third asseR,ment citeda court order as the reason forreferral.

The relationship between numberof drinking problems and perceivedneed for treatment was examined ateach assessment period. At the fistassessment, persons who reportedno need for treatment reported amean of 2.0 problems, whereaspersons reporting a need for treat-ment reported a mean of 5.7 prob-lems. No significant relationship

Allen Heinemann, Ph.D., meets with project members (left to right) Elizabeth Rogers,Matthew Doll, and Nancy Goranson. Heinemann was awarded a grant by the NationalInstitute on Alcohol Abuse and Alcoholism to study the prevalence of and rehabilitationoutcomes associated with alcohol use following spinal cord injury

was found at the second and thirdassessment periods.

Collectively, 11 percent of thesample reported receiving alcoholtreatment at some time, althoughmost of those receiving treatmentdid so before injury. The relativelylow rate at which persons believedthey needed treatment for drinkingproblems, despite the high preva-lence of drinking and alcohol-related problems, may reflectindividuals at different stages of theaddictive process (see Prochaskaand Di Clemente 1986). Consistentwith the findings of Marlatt andcolleagues (1988), the fact of injuryfor persons who were intoxicatedmay have served to illustrate theextent of their drinking problemsand motivated them to initiate be-havior change. However, the majorreason for not pursuing treatmentwas changing one's mind about theneed for treatment. This change inbelief can be understood as an as-pect of denial or rationalizationabout the severity of alcohol-relatedproblems.

No one in the Chicago samplewho believed that treatment wasneeded asserted that social supportor self-initiated attempts to controldrinking were successful. For per-sons who obta led treatment, exter-nal agents (en ,loyers, courts,family, and physicians) most often

were cited as a reason for pursuingtreatment.

Although some drinkers did stopor reduce their drinking after trau-matic injury, others dia not. Thisfinding supports the theory that theacknowledgement of drinking prob-lems is a developmental process. Asalcoholism treatment professionalscontend, more than a major lifedisruption appears sometimes to berequired to convince an aicotolabuser to seek treatment. Thus,spinal cord injury appears to do nomore to cure drinking problems forsome persons than do job loss,divorce, and other forms oftrauma. However, SCI does appearto present an opportunity for exter-nal agents to intervene on behalf ofalcohol abusers who becomeinjured.

SCI AND THE ADDICTIVE PROCESS

The results of this study help toidentify stages of change in addic-tive processes. SCI provided an...pportunity for some persons torecognize the seriousness of theirproblems with alcohol and to makechanges in their drinking patterns.For most, this change was achievedwithout professional assistance. Yetothers continued to drink and todrink heavily, a testament to thepernicious quality of alcohol addic-tion. It may be that some partici-

1M

pants with pre-injury drinkingproblems were early onset drinkerswhose drinking reflects a geneticcomponent. The success of rehabili-tation interventions that considerfamilial and persor.....:i inking his-

! tories are apt to be greater than6 interventions that do not.g As with most studies, caution

should be exercised in generalizing8 these observations to all persons

E with SCI. Participants were re-cruited from one rehabilitationhospital, albeit with a large, diversecatchment area. Whereas refusal toparticipate in the study did notappear to bias the results, the ten-dency of persons with less formaleducation to cease participation inthe study may signal that individ-uals who completed more years offornial education (and who mostlikely enjoyed higher socioeconomicstatus and stronger social supports)were those assessed at the thirdinterview. Replication of these ob-servations will be important togeneralize these results with confi-dence to other populations.

Future studies should investigatethe extent to which early postinjurydrinking patterns continue overtime. The ways in which drinking isrelated to morbidity, vocationaloutcome, and independent livingalso require examination.

THE NEED FOR ALCOHOL

INTERVENTION IN REHABILITATIVE

CARE

Several observations for enhancingthe rehabilitation care of personswith recent SCI emerged as a resultof the study. First, assessment ofalcohol use and alcoholism shouldbe a routine part of all inpatientscreenings in acute care and rehabil-itation programs for persons withtraumatic injury. Responsibility forthis screening could be assumed bya variety of team members, includ-ing representatives from medical,nursing, psychology, or sociai workdepartments.

ALCOHOL HEALTH RESEARCH WORLD

Second, appropriate training ofmedical and allied health teammembers to recognize alcohol abuseis essential. Alcoholism treatmentprogram professionals are possibleresources for providing this knowl-edge to physical medicine specialistsand rehabilitation care providers.

Third, establishing referral net-works to alcohol treatment pro-grams is necessary if potential dualdisabilities are to be identified andtreated in a timely fashion. In addi-tion, sL,Jnd communication linksmust be established so that alcohol-ism treatment programs and alco-holism counselors learn about thespecial needs of patients with dis-abilities. Accessibility needs, func-tional abilities, and attitudestoward persons with disabling con-ditions are some of the topics thatmight be addressed by trainingprograms for alcoholism treatmentpersonnel. Chemical dependencetreatment programs designed spe-cifically for persons with physicaldisabilities are another treatmentalternative (Anderson 1980-1981;Lowenthal and Anderson 1980-1981; Sweeney and Foote 1982).

Finally, the findings of this studyhighlight potential hospital policyissues. Policies regarding possessionand use of alcohol and recreationalor socialization programs that in-corporate alcohol use need to bereexamined and perhaps reformu-lated in light of studies examiningcontrolled drinking outcomes.Whereas alcohol used in modera-tion is likely to pose few problemsfor many patients, those who havehistories of alcohol abuse may bef ncouraged to abuse alcohol bypolicies and programs that provideopportunities for alcohol consump-tion. A case-by-case assessment ofeach patient's history and socialneeds should precede any exposureto alcohol.

Persons with addiction problemswho incur traumatic injury havespecial needs that require close

collaboration of alcoholism treat-ment and rehabilitation medicineprofessionals. The opportunity toprofit maximally from physicalmedicine and rehabilitation pro-grams is unlikely if addiction issuesare not addressed early afterinjury.

Support for this project was provided by theNational Institute on Alcohol Abuse andAlcoholism (ROI AA07111), the NationalInstitute on Disability and RehabilitationResearch ((;00863120), the Spinal CurdResearch Foundation (NBO-611), and theRehabilitation Institute of Chicago. Theauthors extend their gratitude for datacollection to Scott Allen, Anastasia Arm-strong, Kevin Armstrong, Michael Asher,Michael Brandt, Kyu Man Chae, CarolDell'Oliver, Robert Donohue, Mark God-dard, Nancy Goranson, Debra Kiley, BrianMamott, Tami McGraw, William O'Brien,Susan Paradise, Elizabeth Rogers, and JonWemand.

REFERENCES

ANDERSON. P Alcoholism and the spinalcord disabled: A model program. AkoholHealth et Research World 5:37-41,1980-1981.

BRAN DSMA, J M.; MAInTse- 4.0 ; ANDWELSH, R.J. Outpatient Theutment of Alco-holism: A Review and Comparative StudyBaltimore: University Press, 1980.

CAHALAN, D , CISIN, 1.H., AND CROSSLEY, H.M

American Drinking Practices. A NationalStudy of Drinking Behavior and Attitudes.New Brunswick, NJ: Rutgers Center forAlcohol Studies, 1969.

DONOV, , J.E ; JESSOR, R.; AND JESSOR, L.

Problem drinking in adolescence and youngadulthood. Journal of Studies on Alcohol44:109-137, 1983

Fn I MORE, K.M. Drinking and problemdrinking in early adulthood and middleageAn exploratory 20-year follow-upstudy. Quarterly Journal of Stuch&. onAlcoholism 35:819-840, 1974.

FRISBIE. J.H, AND TUN. C.G. Drinking and

spinal cord injury. Journal of the AmericanParaplegia Society 7.71-73, 1984.

FULLERTON, D; HARVEY, R.; KLEIN. M ; AND

HOWELL. T. Psychiatnc disorders in patientswith spinal cord injuries. Archives of Gen-eral Psychiatry 28.1369-1371, 1981.

GALBRAITH, S.; MURRAY, W.; PATEL, A.; AND

KNirr-JoNEs. R. The relationship betweenalcohol and head injury and its effects on

VOL 13, Na 2,1189

the co..scious level. British Journal of Sur-gery 63:128-130, 1976.

GALE, J.; DD MEN, , WYLER. A., TEMKIN, N.;

AND MCCLEAN. A. Head injury in the PacificNorthwest. Neurosurgery 12:487-491, 1983.

GLASS, E.J. Problem drinking among theblind and visually impaired. Alcohol Healthet Research World 5:20-25, 1980-1981.

HEINEMANN, A; DONOHUE, R.; KEEN, M.; AND

SCHNOLL, S. Alcohol use by persons withrecent spinal cord injuries. Archives ofPhysical Medicine and Rehabilitation69:619-624, 1988a.

HEINEMANN, A.; SCHNOLL, S.; BRANDT, M.;

MALTZ, R ; AND KEEN, M Toxicology screen-

ing in acute spinal cord injury. Alcoholism.Clinical and Experimental Research 12:815-819, 1988b.

HEINEMANN. A.W.; GORANSON, N ; GINSBURG, K.;

AND SCHNOLL, S. Alcohol use and activitypatterns following spinal cord injury. Reha-bilitation Psychology, in press.

JOHNSON. D.C. "Alcohol Use by Persons withDisabilities." Unpublished manuscript,Wisconsin Department of Health and SocialServices, 1985.

LOWENTHAL. A., ANC ANDERSON, P. Network

development: Linking the disabled commu-nity to alcoholism and drug abuse programs.Alcohol Health & Research World 5 '6-19,1980-1981,

MA RLATT. G A.; BAER. J.S.; DONOVAN. D.M.,

AND KIVLAHAN, D R. Addict:Ve behaviors:

Etiology and treatment. In: Annual Reviewof Psychology. New York: Annual Review,Inc., 1988. pp. 223-252.

National Institute on Alcohol Abuse andAlcoholism. National Alcohol ProgramInformation System (NA PIS). Washington,DC: Supt. of Does., U.S Govt. Print. Off.,1979.

O'DONNELL, J.J.; COOPER. I.E.; GESSNER, J E.;

SHEHAN, I , AND ASHLEY. J Alcohol, drugsand spinal cord injury. Alcohol Health &Research World 6:27-29, 1981-1982.

PROCHASKA. J 0 , AND DICLEMENTE, C C.

Toward a comprehensive model of change.In: Miller, W.R , and Heather, N., eds.Theating Addictive Behaviors: Processes ofChange. New York: Plenum, 1986. pp. 3-27.

RASMUSSEN. G., AND DEBOER, R Alcohol and

drug use among clients at a residentialvocational rehabilitation facility. AlcoholHealth et Research World 5:48-56, 1980-1981.

SWEENEY, T.T., AND FOOTE, J.E. Treatment of

drug and alcohol abuse in spinal cord injuryveterans. International Journal of the Addic-tions 17:897-904, 1982.

117

ableu k

Alcohol and Other D

Colle

rugAmong OrthopedicallyImUse

ge tudentsPaired

S

L

Students with severe orthopedicimpairments may be especially vulneraoleto abusing alcohol or other drugs.

DENNIS MOORE. M.A., ANDHARVEY SIEGAL, PH D.

College students are chal-lenged by opportunitiesto experiment with illegaldrugs and by occasions

when excessive drinking seems to beencouraged. It is reported that 70to 80 percent of college students areregularmonthly or more frequentconsumers of alcohol and that only10 percent report abstinence (Friendand Koushki 1984; Berkowitz andPerkins 1986; Johnston et al. 1986-Salt? and Elandt 1986). Approximately 25 to 40 percent cf collegestudents are reported to use mari-juana (Friend and Koushki 1984;Johnston et al. 1986).

Students with severe orthopedicimpairments may be unusuallyvulnerable to abusing alcohol andother drugs. Compounding theavailability of alcohol and otherdrugs in many college settings is theavailability to many orthopedicallyimpaired students of medicationsprescribed to ameliorate the effectsof their disabilities. Narcotics maybe prescribed to ameliorate pain, orantidepressants may be prescribedto relieve depression associated with

DENNIS MOORE. M.A., is a certifiedalcoholism counselor completingdoctoral studies in counseling andcounselor education at IndianaUniversity, Bloomington, Indiana.HARVEY SIEGAL, PH.D., is director ofSubstance Abuse Intervention Pro-grams at the School of Medicine,Wright State University, Dayton,Ohio. Comments on this articlemay be addressed to Dennis Mooreat W.I.P./S.O.M., Wright StateUniversity, Dayton, Ohio 45401.

2t

loss of mobility. At the same time,factors such as low self-esteem,social isolation, and unresolvedanger may exacerbate tendenciestoward alcohol and other drug use.Dean and col:eagues (1985), in astudy comparing college drug usepatterns between students with andwithout disabilities, discovered fewsignificant differences between thetwo groups in frequency and typesof drug use. The disabled groupreported less alcohol consumptionthan the nondisabled group, butillicit drug use was approximatelythe same. The study's disabledpopulation of 66 students included20 orthopedically impaired individ-uals, but this subset was not differ-entiated from other disabilities inthe analysis.

Other studies provide contradic-tory findings. Hepner and col-leagues (1980-1981) reported thatapproximately 25 percent of theclients at a rehabilitation centerabused drugs. They also reportedthat 41 percent of the prescriptionsreceived by their clients were medi-cally unnecessary. A study of over250 clients at a residential rehabili-tation facility reported that theproportion of clients using alcoholand other drugs was much higherthan the general population figurefor the same average age of 26 years(Rasmussen and DeBoer 1980-1981). A recent study of 205 physi-cally disabled adults (Meyers et al.1988) suggested that 16 percent ofthe respondents drink beer on atleast 14 days of the month and thatthe same percentage drink at least 4beers per episode. In that samesample, 25 percent of the group usemarijuana more than once amonth.

Possible explanations for thereported tendency of physically

VOL. 13, Na 191! j 119

Orthopedical!y Impaired College Students

impaired individuals to engage inalcohol and other drug use rangefrom self-medication to reducechronic pain or physical discomfort(Sullivan and Guglielmo 1985;Benedikt and Kolb 1986) to morecomplex psychological rationales.For example, DeLoach and Greer(1981) noted that proneness to useof fantasy as a vicariou-, form ofexperience may have unusual signif-icance for nersons with physicallimitations; alcohol or other druguse may be initiated as a means ofescaping reality or enhancing fan-tasy. In addition, Krupp (1968)suggested that trauma associatedwith a disabling injury may leadat least temporary loss of controlover use of mood-altering sub-stances, and Prescott (1980) sug-gested that diminished physicalsensation may instigate elcohol orother drug abuse.

A SURVEY OF ALCOHOL AND DRUG USE

AMONG PHY, `ALLY IMPAIRLJ

STUDENTS

In light of the contradictory find-ings on the relative lcidence ofalcohol and other drug abuseamong physically impaired youngpeople, the authors undertook anexamination of alcohol and otherdrug use among 5' college studentswith orthopedic disabilities. Threebasic hypotheses were posited basedon the literature and clinicalobservation:

Nonprescription drug use ishigher among students with phys-ical L.sabilities than it is amongnondisabled students.Alcohol and other drug choiceamong students with orthopedicimpairments is dictated by factorsunique to the disability.'nauma victims tend to exhibitmore problematic or high-risk usethan persons with congenitaldisabilities.

125

The study was conducted at a mid-vestern university that maintains apositive posture toward physicallyimpaired persons. To maintainhomogeneity in the sample, partici-pation as a respondent in the studywas limited to students who usewheelchairs for primary moh:1;ty.School authorities estimated ap-proximately 80 students with thislevel of orthopedic impairment wereactively enrolled during the studyperiod.

A 104-item questionnaire wasdevised and field tested amongorthopedically impaired collegealumni before be,ng converted to .

self - administered computer testhoused in an open computer lab.Active recruitment of subjects in-cluded individual solicitations. Atotal of 57 students (71.3 percent ofestimated population) completedthe study; this level of participationis perceived to have been a functionof the anonymity of the question-naire and a $10 stipend offered torespondents.

Thirty-eight respondents (66.7percent) reported that their impair-ment resulted from either a traumaevent or from another postnatalcondition; the remaining 19 re-ported congenital disability. Thirty-five respondents (61.4 percent) weremale, and all but two were white.Median sample age was 21Approxinniely 85 percent of thesample reported living away fromtheir families of origin while at-tending school, with the majorityliving in dormitories or other cam-pus housing.

' For example, it was assumed from chnica.contacts and previous literature (Malec et al.1982) that the incidence of marijuana useamong orthopedically impaired studentswould be greater than it was among othercollege students, due to bladder problemsassociated with alcohol consumption amongphysically impaired populations. Surveyresults indicated that this is not necessarilycorrect.

For analytic purposes, the au-ti'ors created a variable to measureth' extent of problems associatedwith Audents' list of alcoholand oth.a- drugs. This variable,described as "Problem Use," con-s:s:ed of an additive score on 18items similar to those included inthe Michigan Alcoholism ScreeningTest. Answers to questions aboutstudents having hangovers, fig,.ts,illness, legbag accidents, inadver-tent injuries, and class attendancewhile "high" were among the datacompiled along with reported dailyconsumption patterns of nonpre-scription drugs (see Table 1). Prob-lem Use scores obtained from thisprocess ranged from 0 (14 respon-dents) to 15 (1 :espondent), with amean of 3.03 and a standard devia-tion of 3.35.

Symptoms of problem use werecompared with a number of inde-pendent V3 riables includira respon-dem age, gender, grades, housing,impairment, chronic pain level,attitude toward impairment, sexualcontacts, and medication. Otherquestionnaire components includedthe Perceived Benefit of DrinkingScale (Petchers and Singer 1987)and Srole's Anomia Scale (Dull1983)- both _ point Guttman scaletrue/false tests that have been uti-1 :zed ir. pleviou- drug studies. TheThrill Seeking lndex-S,S scale IV(Zuckerman 1979) also was in-cluded with four items adapted toapply to wheelchair users. Thrillseeking scores consis'ently havedemonstrated strong correlationswith nonprescription drug useamong general college populations(Brennan et al. 1986; Jaffe andArcher 1967).

RESULTSTRAUMA VICTIMS DOW), \TE

HIGH PROBLEM USE SCORES

The overall alcohol and other druguse levels reported among the sur-vey respondents (see Table 2) ap-

ALCOHOL HEALTH itzscutcw WORLD

Otodilloollos So Problem Ike Soots

nfnflnittlyely alcohol or other drug useIke Loss of friends or other impor-

tant relationship due to alcoholor other drug useExperienced withdrawal from.

habit7forinhis druPSnif*Onty while intoxicated or

rbladder accidentintoodelied or "high"

--llonigenple *Mond me usetheta ,do"

*-44440kcanimbis, barbiturate,, cocaine, or nar-k=-mod *-

*Wet TS Pais for each drug)Aka* cannabis, barbiturate,

.,'cocaine, or ear-; . y ePhodes 0

ParrAireach dra Ja**1113.0110iin use

This** is jatended for intra-gtosPoompaison only. It is ori-eittedhstaatienally toward Seriousor rem* symptom., of abuse todiscourage "false positive' .scores.

flosorlhoy Uspettooslitod Us%

Motilhly Loss Then NoSIAM or Mows Clueo pot Month Ws

5.3

10.5

5.3

7.0'

3.5

10.0

64.9

87.7

84.2

91.2

91.2

96.5

VOL 13, No. 2, 19892

pear comparable with that ofgeneral college cohorts (Friend andKoushki 19R4; Berkowitz andPerkins 1986; Johnston et al. 1986;Saltz and Elandt 1986). Data ob-tained on the Problem Use variable,however, produced striking results.Of the 11 individuals who scored 5or more on the Problem Use varia-ble, non,.. had a congenital impair-ment and 9 reported a trauma eventas the cause of their physical im-pairment. Most surprising was therealization that 8 of the 9 traumavictims in this group reported useof alcohol or other drugs at thetime of their disabling injury. Thisfact, combined with their highProblem Use scores, implies thP1their current alcohol-and otherdrug-related problems predatedtheir disability.

Similarities among the II mostproblematic users suggest a natu-rally occurring cohort, representing19.3 percent of the total sample.Significantly, the results of previousstudies indicate that 20 percent ofthe general college population are

abusers or potential abusersof alcohol or other drugs (Gada-letto and Anderson 1986). As ex-pected from previous literature onale .ol use by college students(Berkowitz and Perkins 1986; Tem-ple 1987), seven of the eight victimsof drug-related trauma who scoredrelatively high on the Problem Useindex were men. An unexpectedfinding was that the two respon-dents with nontraumatic impair-ments and high Froblem Use scoreswere women.

WHY ARE ALCOHOL AND OTHER

DRUGS USED AT PROBLEMATIC LEVELS?

Table 3 provides Spinrmaa correla-tion coefficients of selected varia-bles with Problem Use sLvres. Thevariables correlate(' most highlywith Problem Use were thrill seek-ing, sexual activity le iel (protlhlv acovariate of thrill seeking), anc

1:1

Orthopedically Impaired College Students

scores from the Perceived Benefitsof Drinking Scale. Expected predic-tor variables of medication levels,chronic pain, anomie, etiologies ofdisability, and attitudes towarddisability did not correlate withProblem Use at significant levels.However, use of the chi squarestatistical test matching the dichot-omous variables of trauma/congenital etiology versus high/lowProblem Use score indicated thattrauma victims were more likelythan congenitally impaired studentsto score high on Problem Use (chisquare of 6.815, p< .009).

The use of alcohol and otherdrugs by the orthopedically im-paired college students correlatedmost highly with social and enpho-dant effects, rather than with anyperceived stress-reducing or analge-sic properties. High thrill seeking,for example, had the highest corre-lation with Problem Use amongthis sample, irrespective of varia-bles specific to disability-generatedconsumption. These findings sug-gest that physically impaired collegestudents tend to use alcohol ando",er drugs for reasons common toother college students.

MEDICATION USE AND ALCOHOL AND

OTHER DRUG ABUSE

A majority of the sample (61.4percent) reported use of at least oneprescribed drug, and 48.7 percentcf those on medication (30 percentof the total sample) reported use ofat least three prescribed medica-tions concurrently. In fact, 14.3percent of the students receivingmedication used at least five medi-cations concurrently. Estimatingpharmacological effects of alcoholor other drugs on multiple prescrip-tions is extremely difficult and sub-ject to wide individual variation.

Several respondents expressedawareness about the problems asso-ciated with drug tolerance and po-tentiation, but few respo.ided that

122

Table 3 flpoormao Come lotion Coolllolonte for Solootod Verbalise

Problem roll Seeking Samuel Perm Imd Omer laUse locket Score AM any of Orfoldng Sooty

ProblemUse .464 .379 .329

ThrillSeeking .526 .282

SexualActivity .263

The 016010111CIPV1141i14110011001*6t 6111 two voiebble. The =WOW o ProblemUse allAlbilt, triffollialkMoOlaf 0(4003, Sad lh000nrelation cProblellt l'*f014r< .0037; as Controlled for open-

plibelverffirehillsoll WokingScale .., .048).

--, : 'n---

Table 4}

_

. Puma,* ofRespopanls Replan. Um

30.8

7)3

Artfi0 badliWY:171 1.8

Blood Illi(l'iAptiiNDr 8.8

29.8

Other 47.4

more education or information wasnecessary. This perceived lack ofneed for more information abouttheir medication was contradictedby the results of an exercise inwhich respondents were providedexamples of common medicationsfor each drug class and asked toreport prescribed medications bythose groups (see Table 4). In spiteof examples provided, many stu-dents were unable to recognize theappropriate drug class of their med-ications, as eNidenced by the largenumber of responses in the "other"category.

in addition to the low level ofinformation on pharmacokineticsof their current prescriptions, 43.9percent of the sample reported

2;,

receiving no medical informationon how their physical impairmentmight influence alcohol or otherdrug tolerance.

SUMMARY

The results of this study provideinformation in three major subjectareasetiologies of problem useamong students with disabilities,comparisons of use between dis-abled and nondisabled students,and concerns about medication.

The findings are intriguing in thesupport they lend to traditionaltheories concerning initiation ofalcohol and other drug abuse. Inthis study, these traditional descrip-tors seemed to hold ascendancyover factors unique to physical

ALCOHOL HEALTH & RESEARCH WORLD

impairment. Abuse of mood-altering drugs, including alcohol,appears to have predated disabilityfor the most problematic cohort inthis study. A trauma-related disabil-ity correlated with greater likeli-hood of alcohol or other drugabuse during college than did acongenital disability. This was espe-cially true if the trauma occurredwhit: the individual was under theinfluence of mood-altering drugs.

The incidence alcohol andother drug use of this sample ap-pears comparable to use reportedfor high school and college studentpopulations. As is true in the gen-eral college student population,thrill seeking attributes, previoushistory of drug use, and level ofsexual activity correlated with cur-rent alcohol and other drug usepatterns.

Only 16 percent of the respon-dents thought that they were over-medicated. However, the issue ofprescribed medication interactingwith alcohol or other drug use wasraised by results indicating that 30percent of the sample were takingthree or more concurrently prescribed drugs. Over one-third of thesample (36.8 percent) reported twoor more episodes of physical illnessfollowing alcohol or other nonpre-scription drug use, suggestli,: thepossibility that prescribed medica-tions may potentiate effects of alco-hol or other drug use among thispopulation. This is particularlytroublesome because much of themedication is used over extendedperiods of time or in recurring regi-mens. Alumni in the pilot studyhad reported planning for eveningsof drinking by discontinuing certainmedications in advance; however, itis difficult to control unwantedoutcomes when the drug actions arenot understood by the person at-tempting to control the drug intake.

Subsequent studies should pro-vide greater understanding of these

factors, including understanding ofalcohol and other drug abuse epi-sodes that predate impairment. Assuggested by Glass (1980-1981), itis important to distinguish betweenalcohol or other drug abuse thatpredates the impairment-produzingtrauma and abuse that postdates itas a reaction to the injuries. Therelationship between use of pre-scribed medication and use of non-prescription drugs, includingalcohol, requires further elabora-tion, as do intervention strategiestailored for the physically impairedalcoholic or drug abuser.111

REFERENCES

BENEDIKT, R.A., AND KOLB. L.C. Preliminaryfindings on chronic pain and posttraumaticstress disorder. American Journal of Psychi-atry !43:908- 910,1986.

BERKOWITZ. A., AND PERKINS, W. Problem

drinking among college students: A reviewof recent research. Journal of AmericanColfte Health 35(1):21-28, :986.

BRENNAN. A.; WALFISH. S.; AND AIJBOCHON, P.

Alcohol use and abuse in college students: Areview of individual and personality corre-lates. International Journal of the Addic-tions 21(4 - 5):449 -474, 1986.

DEAN, J.C.; Fox, A.M.; AND JENSEN. W Drugand aicohol use by disabled and nondisabledpersons: A comparative study. InternationalJournal of the Addictions 20(4):629-641,1985.

DiLOACH. C., AND GREER, B.G Adjustmentto Severe Physical Disability: A Metamor-phosis. New York: McGraw-Hill, 1981.

DULL, R. An empirical examination of theanomie theory of drug use. Journal of DrugEducation 13(1):49-62, 1983.

FRIEND, K AND KOUSHKI, P. Student sub-stance use: Stability and change acrosscollege years. Inte, ational Journal of theAu'dictions 19(5):571-575, 1984.

GADALETro, A., AND ANDERSON. D. Contin-

ued progress: The 1979, 1982, and 1985college alcohol surveys. Journal of CollegeStudent Personnel 27(6):499-509, 1986.

GLASS, E. Problem drinking among the blindand visually impaired. Alcohol Health &Research World 5(2):20 -25, 1980-1981.

HEPNER, R.; KIRSHBAUM. H.; AND LANDES, D.

Counseling substance abusers with addi-f

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tional disabilities: The center for indepen-dent living. Alcohol Health & ResearchWorld 5(2) 11-15, 1980-1981.

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JOHNSTON, L.; O'MALLEY, P.; AND BACHMAN, J.

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MEI ERS, A.; BRANCH, L. AND LEDERMAN. R.

Alcohol, tobacco, and cannabis use byindependently living adults with majordisabling conditions. International Journalof the Addictions 23(7):671 -685, 1988.

FETCHERS, M., AND SINGER, M. Perceived-

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PRESCOTT, J.W. Somatosensory affectionaldeprivation (SAD) theory of drug and alco-hol use. In: Lettieri, D.J.; Sayers, M.; andWallenstein-Pearson, H., eds. Theories onDrug Abuse: Selected Contemporary Per-spectives. NIDA Monograph Series No. 30.DHHS Pub. No. (ADM)80-967. Rockville,MD: National Institute or Drug Abuse,1980. pp. 286-296.

RAsmussEN, G., AND DEBOFR, R. Alcohol anddrug use among clients at a residentialvocational rehabilitation facility. AlcoholHealth & Research World 5(2):48 -56, 1980-1981.

SALTZ, K. AND ELANDT, D. College student

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SULLIVAN. A., AND GUOLIELMO, R Chronicimperceptible pain as a cause for addiction.Journal of Drug Education 15(4):381 -386,1985

TEMPLE, M. Alcohol use among male andfemale college students: Has there been aconvergence? Youth and Society 19(1\ 44-72,1987.

ZucxEame.N. M. Sensation Seeking: Beyondthe Optimal Level of Arousal. Hillsdale, NJ:Lawrence Erlhaum Associates, 1979.

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3

Arthritis is a term used toindiLute the presence ofa rheumatic conditionaffecting the joints. A

common misconception is thatarthritis represents a single illness.In fact, there are more than 100distinct diseases that may involvethe joints.

Many arthritic disorders arechronic in nature, result in signifi-cant disability, and require a long-term commitment to management.lbgether, arthr'tic and other rheu-matic diseases are the most wide-spread chronic disabling conditions.The U.S. National Center forHealth Statistics estimates thatnearly 31 million Americansincluding more than 5 million be-tween the ages of 18 and 44 yearshave at least o. form of theseconditions. Approximately 6 mil-lion suffer activity limitation be-cause of arthritis or otherrheumatic disease. These disablingeffects are twice as common amongwomen as among men and are espe-cially prevalent among low-incomeAmericans (US NCHS 1984).

Clinicians know that the arthriticdiseases have a variety of causes,including infection, metabolic ab-normalities, and injury to the im-mune system. Most individual casesof arthritis can be traced to one ormore of these causes without refer-ence to the patient's use of alco-holic beverages. However, it is lesswidely recognized that chronic

DAVID J. NASHEL. M D., is chief ofthe rheumatology section of theVeterans Administration MedicalCenter of Washington, DC, andassociate professor of medicine atGeorgetown University.

ALcouoL Hum & RIDIZARCH WOIU.D

alcohol abuse may be a predispos-ing factor for several varieties ofarthritis. Further, these disordersmay be so severe and crippling thatin the mind of both clinician andpatient, the arthritic diseases ulti-mately may overshadow their rootcause, which is the alcoholism.

THE ALCOHOL-GOUT CONNECTION

Gout is an arthritic disease derivedfrom elevated levels of uric acid inthe blood. In some patients withelevated uric acid levels, crystals ofurate form in the joints. What en-sues is an inflammatory reactionmanifested by swelling, redness,and intense painthe hallmarks ofacute gouty arthritis.

In the early phase of the disease,attacks of gout are infrequent andof relatively short duration. With-out treatment, a single episode maylast from 1 to 2 weeks. With thepassage of time, however, goutyflares usually become more numer-ous and the condition may evolveinto one in which there is chronicinflammation involving multiplejoints. In tnis stage, gout is oftencrippling and deforming and iseasily mistaken for longstandingrheumatoid arthritis.

Clinicians long have recognizedthat acute attacks of gout often arerelated to overindulgence in alco-hol. In a classic treatise o gout,Garrod (1859) stated that:

. . . the use of fermented oralcoholic liqi:ors is the mostpowerful of all the predisposingcauses of gout; nay so potent,that it may ',)e a question whetherthe malady would ever have beenknown to mankind had such.beverages not been indulged in.(p. 260)

The association of gout with alco-hol abuse is highlighted by a recentstudy of patients seen in a familypractice (Sharpe 1984). In thisstudy, the average weekly alcoholintake of patients with gout wasfound to be more than twice that ofa matched control group.

The bases for the alcohol-goutconnection only recently have be-come clear. We now understandthat uric acid is the end product ofthe breakdown of proteins con-sumed in the diet and that alcoholcauses the body to increase produc-tion of uric acid (Faller and Fox1982). At the same time, lacticacidproduced by the chemicalbreakdown of alcohol molecules inthe bodyblocks the normal dis-posal of uric acid by the kidney.Thus, it is not surprising that ele-vated uric acid levels in the bloodresulting in acute attacks of goutmay follow on the heels of a drink-ing binge.

For many centuries, alcoholicbeverages inadvertently have been,ontaminated by lead. Originally,this resulted from the practice ofstoring beverages, such as brandy,in lead casks. This contaminationprovides another connection be-tween alcohol and gout: The term"saturnine" gout is the designationfor a variety of the disease thatdevelops when the patient is a vic-tim of lead poisoning. Saturninegout was particularly common in18th century England when port"fortified" with brandy was a fa-vorite drink.

Saturnine gout remains a com-mon malady to this day, particu-larly in the southern Unite., Stateswhere the illicit production of"moonshine" whiskey contirues.Moonshine frequently contains lead

VOL. 13, Na 2, HO-t7

because the whiskey often is dis-tilled using old car radiators ascondensers; the lead in the connec-tions contaminates the alcohol. Inone study of gout patients admittedbetween 1970 and 1976 to the Vet-erans Administration Hospital inBirmingham, Alabama, 36 percenthad evidence of plumbismachronic form of lead poisoningresulting from their consumption ofmoonshine (Halla and Ball 1982).

SPECIAL CARE IN TREATMENT OF THE

ALCOHOLIC PATIENT WITH GOUT

Because alcohol so often is an incit-ing element in the development ofgouty arthritis, abstinence is a cru-cial part of the management of thisdisorder. In an otherwise healthyindividual, an acute attack of gouteasily is aborted through the useof any one of a variety of anti-inflammatory medications (Schweitzet al. 1978). However, when thepatient has chronic alcoholism, theuse of these agents may pose signif-icant risks.

All of the commonly used anti-inflammatory medications, includ-ing colchicine and the nonsteroidal

anti-inflammatory drugs employedin the treatment of gout, have thepotential to irritate the lining of thestomach. Alcohol also irritates thegastrointestinal tract, and as aresult, the alcoholic patient is morelikely than other patients to de-velop ulcer disease and gastritis, anirritation of the stomach lining.Both ulcers and gastritis may beassociated with blood loss, andthere is a risk of acute hemorrhagewhen anti-inflammatory medicationis used incautiously to treat gout inan alcoholic patient (Nashel andChandra 1982).

125

Arthritic Disease

Another concern in the use ofanti-inflammatory medications istheir potential effects on the pa-tient's blood. Alcoholic patients,for a variety of reasons, are morelikely than other patients to beanemic and to experience prob-lems with blood clotting. Anti-inflammatory medications alsotend to inhibit normal blood coagu-lation and thus may pose an addi-tional danger to patients in this riskgroup.

Acute gouty arthritisalthoughuncomfortable to the patientisusually self-limiting, and attacksoften subside even when untreated.For this reason, it is important toremember the old adage that thecure should not be worse than thedisease. Because anti-inflammatorymedications pose unique risks forthe alcoholic patient, cliniciansshould consider alternative treat-ment regimens. Such alternativesinclude the use of medication forpain relief and the local injection ofcorticosteroid into the affectedjoint or joints.

AVASCULAR NECROSIS: DIFFICULT ToDIAGNOSE AND To TREAT

Avascular necrosis, also known asaseptic necrosis or osteonecrosis, isanother arthritic disorder associ-ated with excessive alcohol intake.With this disease, bone cells die asa result of inadequate blood supply.In the early stages of avascularnecrosis, the areas most often af-fected are the ends of the longestbones. The region of bone affectedlies under the cartilage, the denseconnective tissue that forms thesmooth surface layer of bone andbears the weight of the joints. Intime, the cartilage itself becomes

damaged. Ultimately, arthritis de-velops and the joints may bedestroyed.

The occurrence of avascularnecrosis is correlated with a num-

ber of disorders that may limitblood supply to the bone. The dis-ruption of blood flow may resultfrom a fracture, a spasm, inflam-mation of the blood vessels, orobstruction of the blood vessels bysmall blood clots. When avascularnecrosis is associated with alcohol-ism, some investigators believe thatthe vessels supplying blood to thebone may be obstructed by clumpsof fat globules known as fat emboli(see, for example, Jones et al. 1965and Nixon 1983).

Investigations of the drinkingpatterns of patients with avascularnecrosis have found that as manyas 39 percent of these individualshave a history of significant alcoholuse (Jacobs 1978). Among thesepatients, the head of the femurthe "ball" portion of the hipjointis the bone most often af-fected. Hungerford and Zizic(1978), reporting on 26 patientsdiagnosed with alcohol- associatedavascular necrosis of the hip, indi-cated an average patient age of 38years but found 1 patient who wasonly 16 years old. Particularlytragic was the fact that the diseaseeventually affected both hip jointsin 73 percent of the patientsstudied.

The earliest symptom of avascu-lar necrosis is pain when using theinvolved joint. As the disease pro-gresses, however, pain may bepresent even when the patient is atrest. Unfortunately, there may be adelay from several months to sev-eral years between the onset of painand the time at which changes firstbecome discernible by x-ray. Avariety of other diagnostic proce-dures now can be used to permitearlier detection of the bone dis-ease; among the most promising ofthese are computerized axial tomo-graphy, or CAT scan, and nuclearmagnetic resonance (NMR).

Even with timely diagnosis, treat-ment of avascular necrosis leaves

much to be desired. Of course.after the diagnosis has been estab-lished, further alcohol consumptionmust be discouraged. Unfortu-nately, by the time changes in thebone are evident by x-ray, the dis-ease is likely to have progressed tothe point that eventual destructionof the joints is inevitable.

Several snrgical techniques havebeen used in attempts to reestablishthe blood supply to the affectedbone. However, surgery appears tobe only partially effective evenwhen used in the early stages of thedisease (Lotke and Steinberg 1985).When pain can no longer becontrolled adequately by anti-inflammatory medication and thepatient's disability becomes severe,reconstructive surgery with com-plete replacement of the joint maybe necessary.

ALCOHOL AS AN IMPORTANT RISK

FACTOR IN DUPUYTREN'S CONTRACTURE

Studies of the incidence of Dupuy-tren's contracture, a disease thatinvolves the palm of the hand andthat usually follows a chroniccourse, suggest an association be-tween cases of this condition and ahistory of alcohol abuse. The areafirst affected by the disease is thefascia, a band of fibrous tissue thatlies adjacent to the tendons thatpull the fingers together into aclosed position. In Dupuytren'scontracture, the fascia thickensand, eventually. the skin becomesbound and fixed to this fibroustissue mass. Gradually, at leastsome of the fingersusually thefourth and fifth digitsare pulledtoward the palm and the patientcan no longer fully open the hand.

Dupuytren's contracture oftenaffects both hands in a symmetricalfashion. There appears to be ahereditary predisposition to devel-opment of the disorder, and menare approximately seven times morelikely to be afflicted than are

121ALCOHOL HEAITH * REstAncs Won')

women (Turek 1977). The preva-lence of the disease gradually in-creases with age.

Although Dupuytren's contrac-ture has been associated with suchdiseases as diabetes mellitus andepilepsy, the most striking correla-tion is with chronic alcohol abuse.Attali and colleagues (1987), exam-ining the prevalence of this contrac-ture among hospitalized patients,found the disease present in 32.5percent of patients with alcoholiccirrhosis, in 22 percent with otheralcoholic liver disease, and in 28percent with chronic alcoholismand no liver disease. In compari-son, they found Dupuytren's con-tracture in only 6 percent ofhospitalized patients with nonalco-holic liver disease and in 12 percentof a matched control group. Thesame researchers also noted astrong association between thepresence of Dupuytren's contractureand total alcohol consumptionand discovered a correlation be-tween total alcohol intake and theseverity of the contracture.

In another recent study (Brad lowand Mowat 1986), 64 patients ad-mitted for surgical correction ofDupuytren's contracture answeredquestions regarding their drinkinghistory. Patients with a current ormaximum lifetimz average dailyconsumption of 40 grams or moreof alcoholthe equivalent of ap-proximately four 10-ounce glassesof beerwere classified by thestuoy's authors as "heavy" drink-er,. Thirteen of 54 men with Du-puytren's contracture fell into thiscategory, compared with only 1 of45 male controls without the dis-ease. Among women, 2 of 10 pa-tients with contracture wereclassified as "heavy" drinkers,whereas none of the 44 matchedfemale controls reported similarlevels of alcohol use. These datalend support to the view that Du-puytren's contracture is strongly

Researchers alsonoted a strongassociation betweenthe presence ofDupuytren'scontracture andalcohol consumption.

associated with relatively high levelsof alcohol consumption.

The treatment of Dupuytren'scontracture primarily depends onthe stage of the disease in whichdiagnosis is made and on the rateof progression. In the early stages,physical therapyincluding localheat, exercises, and corticosteroidinjectionmay suffice. However,if there is a significant functionaldeficit or if physical appearancebecomes a major concern, thensurgery often is necessary.

ARTHRITIC DISEASE AS A SIGN AL FOR

THE POSSIBILITY OF ALCOHOLISM

Each of the arthritic conditionsdiscussed above may result in sig-nificant disability to the patient. Inmany instances, the illness can bedirectly attributed to underlyingalcoholism. This recognition byboth physician and patient is cru-cial because continued alcohol usemay further exacerbate these dis-eases. Although most arthritis hasno direct link to alcohol consump-tion, the definitive management ofthese three arthritic disorders byclinicians requires identificationand treatment of any associatedalcohol abuse.

REFERENCES

ATTALI. P.; INK, 0.; PELLETIER, G ; VERNIER,

C.; JEAN, E; MOULTON, L , AND ETIENNE,

J-P. Dupuyten's contracture, alcohol con-

sumption, and chronic liver disease. Ar-chives of Internal Medicine 147:1065-1067,1987.

BRADLOW, A , AND MOWAT, A G. Dupuytren's

contracture and alcohol. Annals of theRheumatic Diseases 45:304-307, 1986.

FALLER, J., AND Fox, I.H. Ethanol-Inducedhyperuncemia: Evidence for increased urateproduction by activation of adenine nucleo-tide turnover. New England Journal ofMedicine 307:1598-1602, 1982.

GARROD, A.B. The Nature and Theatment ofGout and Rheumatic Gout. London: Waltonand Maberly, 1859.

J.T., AND BALL. G.V. Saturnine gout:A review of 42 patients. Seminars in Arthri-tis and Rheumatism 11:307-314, 1982.

HUNGERFORD, D.S., AND ZIZIC, T.M. Alcohol-ism associated ischemic necrosis of thefemoral head. Clinical Orthopaedics andRelated Research 130:144-153, 1978.

JAcoes, B. Epidemiology of traumatic andnontrauraatic osteonecrosis. Clinical Ortho-paedics and Related Research )30:51-67,1978.

JONES, J.P.; ENGLEMAN, E.P.; STEINBACH,

H.L.; MURRAY, W.R.; AND RAMBO, G. Fat

embolization as a possible mechanism pro-ducing avascular necrosis. Arthritis andRheumatism 8:449, 1965.

LCTKE, P.A., AND ST_INBERG, M.E. Osteone-

crosis of the hip an i knee. Buidetin on theRheumatic Diseases :5:1-8, 1985.

NASHEL, D.J., AND CHANDRA, M. Acute goutyarthritis: Special management considerationsin alcoholic patients. Journal of the Amen-can Medical Association 247:58-59, 1982.

NIXON, J.E. Avascular necrosis of bone: Areview. Journal of the Royal Society ofMedicine 76(8):681-692, 1983.

SCHWEITZ, M.C.; NASHEL, D.J.; ft ND ALEPA,

F.P. Ibuprofen in the treatment of acutegouty arthritis. Journal of the AmericanMedical Association 239:34-35, 1978.

SHARPE, C.R. A case-control study of alco-hol consumption and drinking behavior inpatients with acute gout. Canadian MedicalAssociation Journal 131:563-567, 1984.

TUREK, S.L. Dupuytreh's contracture. In:Tbrek, S.L., ed. Orthopaedics: Principlesand Their Application. Philadelphia: J.B.Lippincott Company, 1977. pp. 958-964.

U.S. Natie,aal Center for Health Statistics.Current estimates from the National HealthInterview Survey, U.S., 1983. Vital andHealth Statistics, Series 10. WashingtonDC: U.S. National Center for Health Statis-tics, 1984.

Vol- 13, Na 2, ne 127

Alcohol Abuse and PersonsWho Are Blind

Treatment Considerations

MICHAEL NELIPOVICH, RE.D., AND ELMER Buss

A1984 Wisconsin Stategovernment survey toevaluate alcohol andother drug abuse ser

vices to individuals who are blindor visually impaired led to the con-clusion that this is an underservedpopulation. The fact that no signif-icant data are available concerningsuch services to this group mayindicate that persons with impairedvision are not generally perceivedby treatment programs as a specialclient group. Instead, persons withimpaired vision often are perceivedas isolated cases remembered be-cause of the difficulty and frustra-tion of trying to serve them.

ONSET AND ADJUSTMENT SKILL ISSUES

A person -.vho is blind and abusesalcohol should be considered duallydisabled. In developing a treatmentplan, several things are important.It is important to determine, ifpossible, whether the vision impair-ment or the alcohol abuse occurredfirst. Because every treatment planmust be individualized, each plandiffers in part depending ca thecircumstances under which thedisability begins. If the visual im-pairment is of long standing and ifan appropriate level of acceptance

National Eye Institute

VoL. 13, Na 2, IWO

of and adjustment to this impair-ment has been reached before alco-hol abuse begins, then treatmentshould be geared to addressing thealcohol abuse. If the visual impair-ment has been more recent, thentreatment should focus on helpingthe client to accept and adjust tothe visual impairment first, andthen on treating the alcohol abuse.The greatest challenge to rehabilita-tion professionals occurs when aperson suffers from two or moredisabilitiessuch as alcohol abuseand vision impairmentand hasaccepted neither of them.

Another consideration in devel-oping a treatment plan is the levelof the client's adjustment to thecondition of visual impairment. Allclients, blind or sighted, who areadmitted to alcoholism treatmentprograms hrve attained some levelof independence. In assessing ad-justment skills, the goal is to deter-mine whether or not the client cantravel independently, can send andreceive communication by variousmeans, and can manage clothingand personal needs. Adjustmentskills can be measured by askingspecific questions about indepen-dent mobility, communication tech-niques, and personal management.

30,

The level of a client's adjustmentskills will affect tne ways in whictthe staff of an alcohol rehabilita-tion facility interact with a visuallyimpaired client. The staff can askwhether the patient travels indepen-dently and uses either a long caneor dog guide. Reatment staff, par-ticularly in an inpatient facility,also determine whether or not aclient has the appropriate organiza-tional skills to identify clothing.The absence of such skills mayimpinge upon self-image in a situa-tion in which self-image is already aproblem. The pitfall to avoid istreating the blind patient like achild during assessment.

The accurate assessment of ad-justment skills by treatment staff

MICHAEL NELIPOVICIL RHD., is act-ing director of the Office for theBlind of the Wisconsin Division ofVocational Rehabilitation. ELMER

Buss is employed by the Office forPersons with Physical Disabilitiesof the Wisconsin Division of Com-munity Services. Comments on thisarticle should be addressed to Dr.Nelipovich at the Wisconsin De-partment of Health and SocialServices, I Wilson Street, Room830, P.O. Box 7852, Madison, Wis-consin 53707.

129

Persons Who Are Blind

also includes identification of theclient's preferred mode of commun-ication. During treatment, clientstypically are asked to read a varietyof materials that are viewed as ben-eficial to rehabilitation. Not beingable to access the appropriate print

can be as big a barrier to treatmentas taking steps is to a person in awheelchair or as group sessionsconducted in English are to a cheatwho speaks only Spanish.

The sighted person's first re-sponse to the problem of communi-cating with the visually impairedoften is to have material availableon tape or to have a sighted personavailable to read. These are func-tional approaches, but may not bethe best solutions. For example, ifan alcoholism treatment client islegally blind but can use print withmagnification, treatment facilitiescan purchase or rent the appropri-ate device. Alternatively, if a clientis a braille reader, the facility canprovide at least a copy of the basicmaterial that is already available inbraille. The objective is to assist thepatient in becoming as independentas possible and to increase choicesin rehabilitation.

If assessment of a visually im-paired client's adjustment skillsindicates that there are major gapsin the client's ability to functionindependently, alcoholism treat-ment program staff can contact thelocal State or private agency thatspecializes in services to the blind.Treatment facilities also should beprepared to identify communityresources that can provide any ofthe needed services.

FAcn.rry 13suzs

Blindness restricts control of theenvironment and ease of mobility.Clients are most responsive whentreated respectfully and when as-sumptions are avoided. For exam-

ple, when staff members orient thevisually impaired client to the treat-ment facility, it is wise to askwhether the client has a preferredway of becoming accustomed tophysical surroundings; most visu-ally impaired people have suchpreferences.

Effective orientation of a blindclient to the physical environmentof an inpatient facility includes, ata minimum, familiarity with theclient's sleeping room, bathroom,meeting rooms, dining room, recit-ation room, and all exit locationsWhen sufficient time is spent onthe orientation process, the clientbecomes comfortable with the sur-roundings. The authors' experiencesuggests that a staff member oranother client should be designatedas a guide for the first few days.After this period, most inpatientclients who are blind should ye ableto travel independently. Some indi-viduals may require more orienta-tion and more guided assistancedepending upon the level of theiradjustment skills.

Inpatient treatment facility staffshould evaluate recreational and

3

leisure time activities to determinetheir accessibility to visually im-paired clients. Again, the localservice agency can help to meet therecreational needs of the visuallyimpaired. A multitude of items areavailable for purchase, rangingfrom braille playirg cards to modi-fied table games and craft kits. Thegoal is to allow the blind client toparticipate in the mainstream ofactivit: and not be isolated. Theclosest library for the blind also canbe contacted so that. the treatmentstaff may obtain the adaptiveequipment for cassette magazinesand other materials that are avail-able for nonprint readers.

THE V/PliA.LLY IMPAIRED PERSON IN

ALCOHOLIcs ANONYMOUS

Many counselors advocate partici-pation in Alcoholics Anonymous(AA) for long-term recovery. TheIA system can be most effectivefor persons who are blind if theycan participate fully. Many of thefollowing observations on removingbarriers within AA are equally validfor other outpatient treatment andrecovery programs.

LI ALCOHOL HEALTH & Itzmutat Wo am

Although AA meetings are avail-able 7 days a week at a wide rangeof times and locations, their acces-sibility to the visually impairedrecovering alcoholic is limited be-cause of the inability to drive. Taxi-cabs may provide a solution butcan become expensive. If a blindperson in recovery wants to attendan AA meeting on Saturday morn-ing and the closest one is 15 milesaway, the stress that can result fromtrying to get there can compoundthis person's agony. 11.anspo.-tationcan make all the difference to avisually impaired alcoholic's strug-gle to become and remain sober.

If a visually impaired alcoholic isreferred to AA from treatment, thereferring counselor has a responsi-bility to make the first arrange-ments for transportation to the AAmeeting of choice. Visually im-paired persons should go to therust meeting the best way possibleand explain the need for futuretransportation. A new visually im-paired member and AA oldtimersimmediately can begin working ona list of friendly drivers. The AAoldtimers at the meeting can bemade aware that lack of transporta-tion may result in a serious risk ofnonattendance and eventual re-lapse. Their response is likely to bediligent assistance.

Additional barriers to effectiveparticipation in AA meetings in-clude problems related to the envi-ronment and to socialization. As inan inpatient treatment facility, it isimportant to orient the visuallyimpaired person to the surround-ingswhere entry doors are, howthe room is shaped, how the tablesand chairs typically are arranged,where the coffee pot is, and wherethe bathrooms are located. Theseare basic facts that a sighted personquickly determines upon entering aroom, but that cannot be taken forgranted for a person with impaired

vision. It also is important to ap-preciate that it is awkward for avisually impaired person to movefreely in a crowded room, and as-sistance should be provided whennecessary.

The process of socialization in anAA meeting is assisted when some-one introduces the visually im-paired member to several otherattendees. Members should adoptthe courtesy of identifying them-selves when speaking and telling theblind person when they are depart-ing (see sidebar on personal interac-tion with visually impaired persons).Many sighted people become ner-vous when addressing an individualwho cannot make eye contact whenspeaking, and this nervousness canpromote a feeling of negative self-worth and isolation that is detri-mental to recovery. To counter this,an oldtimer can be assigned to pro-mote introductions and stimulateconversations between the visuallyimpaired person and others untilinteractioi. occurs easily.

It is important to provide alterna-tive communications to reduce thebarriers to full participation inAAand other outpatient settingsby the visually impairer' alcoholic.The schedule and a list of meetinglocations can be made available inbraille. Taped items can be preparedwith the visually impaired recover-ing alcoholic in mind. It is wise tohave audiotapes of The Big Bookand Thelve Steps and Thelve Thadi-tions, but ti hese audiotapes arenot labeled in braille, the blindalcoholic will not be able to deter-mine their contents. Audiotapesused in recovery can also be tone orvoice indexed for the blind, andreaders can indicate wnen one sideis over.

When audiotapes are preparedfor the blind, the appropriate play-back speed is 15/16 rpm instead ofthe standard 1-7/8 rpm. The slower

playing speed saves space and cost:For example, one version of TheBig Book at 1-7/8 rpm contains sixcassette tapes, with two sides percassette, and costs $25, whereas a15/16 rpm version can be recordedon a single cassette and can bemade available for significantly lesscost. Of course, many audiotapesare prepared primarily for sightedpeople to use in standard tapedecks, but with limited modifica-tion, taped AA material can bemade much more accessible to theblind.

THE NEED To REACH Our

Alcohol- and other drug-relatedproblems exist among the blind,and individuals involved in treat-ment services should be aware ofthe responsibility for serving thispopulation. Developing the skillsnecessary to serve this group di-rectly affects the treatment outcomefor blind individuals with alcohol-related problems, as suggested bythe results of an earlier survey ofagencies serving the blind (Nell-povich and Parker 1981). Sixteencounselors who participated in thatstudy could find no employmentfor any visually impaired alcoholabusing client. However, eightcounselors successfully found em-ployment for one-half of the visu-ally impaired client population. Thegreater the knowledge and the morehighly developed the skills of thecounselor, the better the prospectsfor rehabilitation of the visuallyimpaired alcohol abusing clients.

The authors strongly suggest thatthe professionals in alcohol andother drug treatment services con-sult with agencies serving visuallyimpaired persons. la

REFERENCE

NELIPOVICH, M., AND PARKER. R. Comment:The visually impaired substance abuser.Journal of Visual Impairments and Blind-ness 75:305, 1981.

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4

Intervention withVisually Impaired

Children ofAlcoholics

CHRISTINE SAULNIER

Children of aroholics(COAs) are generallyacknowledged to be atincreased risk for devel-

oping alcoholism. At the sametime, the incidence of alcoholism ishigher among the disabled thanamong the general population(Hepner et al. 1980-1981; Hindmanand Widem 1980-1981; Greenwood1984; Gallagher 1985; Sylvester1986). Therefore, one would expectvisually impaired COAs to be atespecially increased risk.

Peterson and Nelipovich (1983)estimate that there are 40,000 visu-ally impaired alcoholics in theUnited States. The number of visu-ally impaired COAs is not known.However, concern about the prob-lem is raised by suggestions made ina treatment group for visually im-paired adolescent and young adultCOAs run by the author. Four outof five members of this group usealcohol, and one-half of those whouse alcohol abuse it. In each case inwhich the child is abusing alcohol,both parents are alcoholic. Bothparents are alcoholic in three out offour group members.

CHRISTINE SAULNIER iS director ofsocial service at Quigley MemorialHospital, 91 Crest Avenue,Chelsea, Massachusetts 02150.

Amencan Council of the Blind 4

Despite the scope of the problem,treatment services for alcoholicsand COAs rarely are designed spe-cifically for the visually impaired.In part, this lack of special servicesis due to the process of "main-streaming," in which it is assumedthat the visually impaired can relyon services geared to meet theneeds of the general population.Suggestions in the literature havebeen limited to educating addictiontreatment professionals regardingvisual impairments and adding low-vision aids to current alcoholismtreatment programs to accommo-date the needs of the visually im-paired (Glass 1980-1981; Neli-povich and Parker 1981).

On a policy level, the Compre-hensive Alcohol Abuse and Alco-holism Prevention, Treatment, andRehabilitation Act Amendment of1979 (42 U.S.C., 1980) requires thatalcoholism treatment services bemade available to "handicapped"persons. In practice, access to alco-holism and other mental healthservices for those with physicaldisabilities has been limited for thefollowing reasons:

Service providers lack educationand training in disabilities aware-ness (Gallagher 1985).The desire to comply with the

133

Visually Impaired Children of Alcoholics

"normalization" campaign thatfocuses - 7 how well people withdisabllit:...s fit into the larger soci-ety (Gallagher losS) leads somepeople with disabilities to mini-mize or deny genuine treatmentneeds.People with disabilities feardouble stigma of disability anddependence on alcohol and otherdrugs and are therefore reluctantto seek treatment (Boros 1980-1981; Hindman and Widem1980-1981; Lowenthal andAnderson 1980-1981).

This article presents strategies forovercoming some of the difficultirencountered in treating visuimpaired COAs. It is basedauthor's experience with a tre...-ment group for COAs residing in aschool for the visually impaired.When asked what would be themost important piece of informa-tion to convey -nembers insistedthat readers be ade to understandthat the similarities between visu-ally impaired COAs and theirsighted peers far outwe'gh the dif-ferences. While this is true, it alsoshould be noted that the problemsshared by all COAs are apt to becompounded and itensified whenvisue1 impairments are present. Thefamily alcoholism counselor's treat-ment approach and emphasis there-fore depend on the needs of thespecific client and on whether ornot the client already has access tospecial services.

T:IE N. URE OF THE IMPAIRMENT

Awareness of a number of factsabout the nato7e of visual impair-ment helps health care providers toavoid clinical misinterpretations.

First, it is important to rememberthat visually impaired does notnecessarily mean completely blind.Ninety percent of visually impaired

The alcoholismtreatme.rit professionalneeds to monitor anytendency towarddecreased expectationsof visually impairedcfients.

people have some degree of sight(N- clonal Society to Prevent Blind-ness 1980). If the client does notrequest assistance, the clinicianshould ask what specific assistanceis needed; trying to force unneededhelp is counterproductive. Othercommon mistakes include ignoringthe visually impaired client andaddressing a companion, equatingblindness with dearnc..: and show.-irg t a visually impaired person,or loc::ing around the room ratherthan directly at the person beingaddressed.

Occasionally a client may exhibitrocking, eye poking or pressing,hard flapping, and head p >Ring.These behaviors, known as "blind-rms," are unrelated to mentalillness ai are not indications ofpathology, althourh they may in-crease in frequency of intensitywhen the client is under stress.They are most co nmon in peoplewho a-e totally and congenitallyblind. Some -isually impaired per-sons who exhibit these behaviorshave been misdiagnosed as athistic.Altho-igh autism does occur amongthe blind, a diagnosis of autismbased solely on the occurrence ofblindisms would probably beinaccurate.

Tt would also be a mistake toassume that sloppiness in self-careor dress is a permanent conditionor that it is necessarily related to

1344 A.

visual impairment. This may be asign of depression, or the clientmay simply need be remindedthat others are favorably affecteuby the appearance of a well-groomed person. The author peri-odically consults with personalmanagement instructors to decidewho will address these issues and toclarity whether the problem is emo-tional or skill based.

Finally, the alcoholism treatmentprofessional needs to monitor waytendency toward decreased expecta-tions of visually impaired clients. Ifgroup members are expected to do"homework," such as reading, writ-ing, or attending a meeting or ac-tivity, he visually impaired clientsshould be held to the same expecta-tions. As one group member said,"If they all clean ashtrays [at Al-Anon meetings], clean ashtrays."

COUNSELING THE RECENTLY IMPAIRED

One of the first steps in beginningtrea'n.ent is to dr'ermine whetherthe client has only recently becomeimpaired. If so, additional therapiesmay need to be incorporated intothe alcoholic -t treatment to addressthe special emotional and physicalneeds of the newly impaired. Con-sultation with a vision expert isrecommended at this stage.

It is important to note that theuse of confrontational techniquesmay be a mistake at this time. Thisapproach, so useful for breakingthrough a COA's denial of familyalcoholism, might be psychologi-caLy harmful to a newly impairedclient whose primary need is sup-port. The alcoholism treatmentprofessional should assist the clientin accepting the impairment andintegrating it into self-concept in apositive way.

In addition to the loss to whichthe client must adjust and to possi-ble related depression, the newly

ALCOHOL HEALTH a Itrumecu %Num

impaired person faces architectural,attitudinal, and employment barri-ers (Glass 1980-1981) that may beinitially overwhelming, decreasingthe client's ability to cope withfamily alcoholism and possibly evenincreasing the risk of the client'sown drinking. The client's aware-ness of both the li.-nitations andpotential for compensating forvision loss may need to be dis-cussed. Encouraging or arranginginteractions with other visuallyimpaired persons will help decreasethe ( dent's sense of isolation andthe teas of in ;lity to cope.

PROBLEMS IN TREATMENT:

DENIAL AND Glam.

Denial of family alcoholism is acommon phenomenon amongCOAs. The problem may becomemore complicated when the COA isvisually impaired. Clients some-times seem to interpret the adage"seeing is believing" quite literally,disregarding information that theyhave obtained through their othersenses. For example, as ev;dence ofalcohol abuse, hearing a parent'sslurred speech seems to be less con-vincing than seeing the parent'sunsteady gait.

Another problem of perception isthat group members tend to evalu-ate the seriousness of a parent'sdrinking problem based on theirpersonal interactfr. s with the par-ent rather than on objective obser-vation. Clients often discount theseriousness of a drinking episodebecause it did not cause clear, im-mediate trouble between the alco-holic parent and other familymembers"My mother and IJidn't fight last night, so she didn'thave too much to drink." ,k . con-cept of alcoholism being h- "iful to0,- alcoholic also seems more diffi-cult to communicate to visuallyimpaired COAs.

The prevalence of denial amongCOAs does nc preclude a sense ofguilt and responsibility for the fam-ily's problems. Here, too, this con-viction seems harder to dispel withvisually impaired COAs. Statementssuch as "If only I'm good enough,my dad will stop drinking" arecommon among COAs; a variationthat surfaced among members ofthe author's treatment group wasthe belief that if they were not visu-ally impaired °.%)ey would be betterable to help their alcoholic parents.It is necessary to state repeatedlythat eliminating the client's visualimpairmrat would not eliminate theparent's alcoholism and that inabil-ity to cure the disease is not relatedto lack of sight.

Clients sometimes insist that ifthey saw better, they woula be lessof a burden to the parent. They

In breaking the silenceabout familyalcoholism, visualimpairment shouldnot be substituted as ataboo topic. 11may even wonder if the reason theparent drinks is because he or sheviews the child as defective. Realis-L discussion of how the visualimpairment affects tie parent's lifesometimes convinces group mem-bers that their impaired vision ismore of an inconvenience to them-selves than to their parents andthat parental inconvenience, whileit does exist, does not causealcoholism.

PROBLEMS IN TREATMENT.

DISCRIMINATION AND SELF -IMAGE

The virtually constant struggle

Vat. 13, No. 2, LW

against discrimination is one of theissues that sets this treatment groupapart. The stigma of family alco-holism, together with the negativeassociations of being blindforexample, the stereotype of the blindperson as a beggar (Glass 1980-1981) can have a devastating ef-iect on self-esteem, exposing thevisually impaired child to an evenhigher risk of continuing the familyalcoholism. Therefore, values clari-fication sessions must focus notonly on beliefs about alcohol con-sumption and alcoholism but alsoon beliefs about visual impair-ments and the culture's view ofcompe nce.

For example, people may reactwith surprise, embarrassment, an-ger, or even disbelief when theydiscover that a visually impairedperson can see. A partially im-paired COA who has been sub-jected to such reactions may needreassurance and support with re-spect to the reality of his impair-ment and the validity of hisself-image.

The specifics of each client'svisual disability are open for discus-sion in the author's group, and aconscious effort is made to identifyand accept one another's needs;group members are not necerilyaware of one another's abilities norare they particularly adept at artic-ulating their own. In breaking thesilence about family alcoholism,visual impairment should not besubstituted as a taboo topic.

As with other COAs, groupmembers are enconraged La re-examine their view of themselves asunlovable. Clients need to be reas-su-ed that visual impairmerL,, andother injuries, even when these aresecondary to alcoholism (for exam-ple, fetal alcohol syndrome ortraunr resulting from alcohol-related ia cidents), do not make

135

Visually Impaired Chilthen of Alcoholics

them unlovable, nor were they de-liberate acts planned by their par-ents to harm them.

Visually impaired COAs may beeven more inclined to see them-selves as different from other COAsand as not capable of being helped.lb combat this perception and toencourage interaction with nondis-abled peers, group members areencouraged to join Alateen or Al-Anon. The combination of specialservices that directly address theirspecific needs and traditional ser-vices for COAs seems to work well.

There is also a tendency by othersto regard the lack of normal visionas a "supreme catastrophe ;fatherthan] a nuisance that can be cir-cumvented or overcome" (Selvin

p. 420) and to see the visuallyimpaired person as being incapableof taking care of himself or herself.All the members of the author'streatment group have been sub-jected to annoying, damaging pityregarding their impairment andtheir capa_ity to cope.

The children in the author's treat-ment group are taught to avoidaccepting the negative impressionsothers may have of them. The im-age of vision loss as a supremetragedy is discussed, challenged,and emphatically denied. Groupmembers arc cl,....ouraged to focuson their skills and their ability tocompensate for their impairment.They are reminded of their aca-demic achievements, their home-making and cooKng skills, andtheir success in such varied activi-ties as acting, mash. athletics, andovercoming negative behaviorpatterns.

The tendency of others to over-protect the visually impaired personinterferes with the goals of familyalcoholism treatment. In adult-hood, when other COAs may beextricating themselves from thedysfunctional family system, thevisually impaired COA may receive

1.36

less support for leaving because ofa perceived need to be protected bythe parents.

Therefore, the need for indepen-dent living should be identifiedduring the "aging out" processthe time when the client makes thetransition from special education toadult services, usually between theages of 21 and 26 (depending onthe State). The clinician can contactthe coordinator of the educationplan and urge that this goal beincorporated into the transitionplan.

COPING WITH VIOLENCE

The combination of overprotectionand involvement in special educa-tion may lead the Professionalsserving the COA to a false impres-sion of safety regarding the physicaldangers of family alcoholism. Evenin a residential school setting, riskis not eliminatedsome childrenwith special needs still go home toalcoholic families.

Therefore, it is essential to reviewrealistically the visually impairedCOA's vulnerability to danger andviolence (Hindman 1977). Groupmembers are encouraged to exploretheir increased risk, to examinecoping skills they have developed inother arenas to compensate forvisual impairments, and to applythe compensatory skills to this situ-ation. The special eaucation systemteaches COAs how to .eek assist-ance, how to call a telephone oper-ator, and how to call a taxicab orthe police if necessary. The author'sgroup discusses the advantage ofkeeping emergency cab fare avail-able and of memorizing telephonenumbers of friends and relativeswho could come to their assistanceif needed.

Group members discuss the dan-ger of trying to intervene in violentsituations. They are encouraged toplan a course of ac :on to be fol-lowed in violent situations: for

4 t.

example, whether it may be safer tocall someone or to leave; and ifthey leave, how they will leave,where they will go, and by whatroute. Independent travel promotedby the special education system isreinforced in consultation with theorientation and mobility trainer toensure that students will not beexposed to further risk by taking anunfamiliar route or traveling by amethod they are not skilled inusing.

OUTREACH

After a -nference in which alco-holism counselors and disabilityrehabilitation professionals sharedinformation and treatment tech-niques, Lowenthal and Anderson(1980-1981) suggested outreachprocedures to identify physicallyimpaired alcoholics and to informthem of treatment options. Theirsuggestions included developing a

referral directory and disseminatinginformation in writing, over thetelephone, and through communityeducation workshops. Supplyingclients with information in brailleor on tape is another possibility(Peterson and Nelipovich 1983).

Mobility and personal manage-ment services may need to be pro-vided to visually impaired clients,particularly for alcoholism treat-ment in a residential setting (Glass1980-1981).

Despite the importance of out-reach efforts designed to breakthrough denial (Bean 1988), thelack of systematic inquiries de-signed to identify alcohol and otherdrag abuse among persons enteringe. rehabilitation program is a seriousprocedural problem. Hindman andWiden (1980 -1981) advocate theinclusion of relevant questions dur-ing the intake interview.

It is important to note, however,that the alcoholism treatment pro-fessional places the special educa-tion system in a precarious position

ALCOHOL HEALTH & IlitszARat WORLD

when requesting that the systemeither confront a parent about fam-ily alcoholism or provide treatmentwithout parental consent (NIAAA1983). The system in this case runsthe risk of alienating the familyand, as a result, perhaps having theparents withdraw the child from thespecial education program. In somecircumstances, special educationofficials may need to be informedabout laws regarding the treatmentof minors without parental consent(see Croxton et al. 1988). To ensurethat alcoholism awareness is partof the special education milieu,arrangements must be made toprovide in-service training to clini-cal and educational staff.

Written screening policies cur-rently are being developed in thesetting of the author's treatmentgroup for incorporation into thestudents' initial evaluation. Memosare sent periodically to social work-ers and psychologists working withvisually impaired students, remind-ing them that the treatment groupexists and that it accepts referrals.Memos are followed up in person,and the clinical supervisor is askedto heir, monitor students for alco-holism treati lent needs. Cross-con..,:lt& on between rehabilitationpro'essionals and alcoholism pro-fessionals, suggested by Lowenthaland Anderson (1980-1981), will beprovided through a local univer-sity's course on rehabilitation ofpersons with physical impairments.

TAKING THE FIRST PRACTICAL EPS

The alcoholism treatment profes-sional can compensate for gaps inknowledf e or experience regardingvisually impaired clients by consult-ing with specialists and takingcontinuing education classes. Place-ment on the mailing list of agenciesserving visually impaired peoplewill remind the alcoholism treat-ment professional of the needs ofthis population. In turn, the alco-

Va.. 13, MA 2, 1,119

holism service provider should keepthe agencies serving visually im-paired persons informed of theavailability of treatment and coun-seling services. Integration ofknowledge can occur in much thesame way as, for example, learningto work with a client who is bothalcoholic and diabetic. By askingfor help, alcoholism service pro-viders may find willing consultantsamong those who serve the special-ized needs of the visually impaired.

Service providers in rehabilitationare encouraged to examine theircommitment to normalization toensure that it does not interferewith the ability to acknowledge

The lack of systematicinquiries . . . toidentify alcohol . . .

abuse among personsentering arehabill tation ogramis a serious problem.alcoholism. The message of nor-malization is that an impaired per-son is, first of all, a person, not tobe defined by his or her impair-ment. Ho;m.ver, normalization canbecome counterproductive if itleads to actual denial of the impair-ment or of problems such as alco-holism. Rehabilitation specialistsmight be asked to provide consulta-tion to alcoholism treatment profes-sionals when a client is referred forservices. Alzoholism service pro-viders can assess their skills andcapacity for providing treatment,consult with those wt o have com-plementary skills, and actively seekto acquire new skills so that visuallyimpaired abusers of alcohol andother drugs and visually impairedCOAs can have their therapeuticneeds addressed.

4?

REFERENCES

BEAN, M. Identifying and managing alcoholproblems of adolescents. Psychosomatics23(4):151-155, 1988.

Boaos, A. Alcoholism intervention for thedeaf Alcohol Health & Research World5:26-30, 1980-1981.

CROXTON, T.; CHURCHU L. S.; AND FELLEN, P.

Counseling minors without parental consent.Child Welfare 67(I):3-14, 1988.

GALLAO/ ER, H. Who cares about disabledpeople? Social Policy 15(I):18-20, 1985.

GLAss, E. ProblPm drinking among the blindand visually impaired. Alcohol Health &Research World 5(2):20-25, 1980-1981.

GREENWOOD, W. Alcoholism: A complicatingfactor in the rehabilitation of disabled indi-viduals. Journal of Rehabilitation 50(4):51-52, 72, 1984.

HEPNER, R.; KIRSHBAUM, H ; AND LANDES, D.

Counseling substance abusers with addi-tional disabilities: The center for indepen-dent living. Alcohol Health & ResearchWorld 5(2):11-17, 1980-1981.

HINDMAN, M. Child abuse and neglect: Thealcohol connection. Alcohol Health &Research World 7(3):2-7, 1977.

HINDMAN, M., AND WIDENS, P. The mulndis-abled: Emerging response. Alcohol Health &Research World 5(2):5-10, 1980-1981.

LOWENTHAL, A., AND ANDERSON, P. Network

development: Linking the disabled commu-nity to alcoholism and drug abuse programs.Alcohol Health & Research World 5(2):18-21, 1980-1981.

National Institute on Alcohol Abuse andAlcoholism. Prevention Plus: InvolvingSchools, Parents, and the Community inAlcohol and Drug Education. DHHS Pub.No. (ADM)83-1256. Washington, DC: Suptof Docs., Govt. Pnnt. Off., 1983.

National Society to Prevent Blindness.Vision Problems in the U.S.: Facts andFigures. New York: National Society toPrevent Blindness, 1930.

NELIPOVICH, M., AND PARKER, R. The visu-ally impaired substance abuser. Journal ofVisual Impairments and Blindness 75:305,1981.

PEransoN, J., AND NELIPOVICH, M. Alcohol-ism and the visually impaired c":,nt Journalof Visual Impairments and Blindness77:345-347, 1983.

SELV1N, H. 1-1,v to succeed at being blind.The New Outlook December:420-428, 1976.

SYLVESTER, R. Treatment of the deaf alco-holic: A review. Alcoholism TheatmentQuarterly 3(4):1-20, 1986,

137

z

Epffepsy, Seizures, and AlcoholMICHAEL J. STOIL, PH.D.

L F

R, r

R T.

ev".41M-404.1

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ri\MAIN ki\ttA/t

rcgw's-v'vt,/ f f 1,11\1 \I. \f" \IVVAArvi6

These wavy line tracings of the electroencephalogram (EEG) show normal bran wavepatterns recorded from eight sites in the brain (far left), followed by the steep "spike andwave" EEG pattern associated with one type of epileptic seizure

child sits on a hospitalbed with her headwrapped in bandages,matting cheerfully with

a visitor about her doll collection.Without warning, she falls silentand her head lolls back against thepillow. The child remains motion-less for several seconds and thenrecovers, resuming her conversationwithout interruption.

A college student is cramminglate at night for a midterm exami-nation, at a desk lit by a flickeringfluorescent light. He suddenly be-comes aware of a peculiar taste inhis mouth, reminiscent of cherries.As soon as the sensation passes, the

MICHAEL J. SMIL, PH D., served asSpecial Focus Editor for this issueof Alcohol Health & ResearchWorld.

13$

hand holding his highlightingmarker begins to twitch spasmodi-cally. Although the student tries tocontrol the movement, the tremorbecomes more violent and gradu-ally "walks up" the arm until everymuscle below the shoulder seems tobe affected. Moments later, thetremor stops abruptly and thestudentshaken in more ways thanonereturns to his books.

Members of the emergency roomstaff examine the pedestrian victimof an early morning traffic acci-dent. The patient's clothes andbreath smell strongly of spirits, andthe patient alternately complains ofhis injuries and demands a drink.Staff members are not surprisedwhen the patient enters into convul-sions that threaten to topple himfrom the hospital gurney.

These three cases are examples ofseizure phenomena. Clinically doc-

A :

umented for centuries, seizuresformerly were believed to result

from the disease of epilepsy. Scien-tists now agree that the term epi-lepsy is similar to the term cancerin if at both terms are applied ge-nerically to several conditions withdiffering symptoms, consequences,and perhaps mechanisms. In gen-eral, epilepsy involves erratic elec-trical activity arising from withinthe central nervous system (CNS),including the brain. The pioneeringstudies of William Gordon Lennox(Lennox 1941) and Maurice Victorand colleagues (N ictor and Adams1953; Victor and Brausch 1967)were particularly important indefining a relationship betweenalcohol use and nervous systemdisorders, including epileptic sei-zures. This work led to identifica-tion of the potential risk forseizures resulting from alcoholabuse and to improvements in thestudy of possible caub.s and con-trolling mechanisms for seizurephenoiliena.

WHAT IS EPILEPTIC SetzuRE?

An epileptic seizure can be definedas the sudden disruption of normalbrain function due to hyperactivityin one or more areas of the CNS.Under nonseizure conditions,groups of nerve cells, or neurons,operate without synchronizationat any given moment, some neuronsare discharging electrochemicalimpulses, some are resting, andsome are priming far the next dis-charge. In primary epilepsy, seizure-related CNS hyperactivity occurswhen groups of neurons synchro-nize their discharges as a singleunit. This phenomenon is known asthe seizure discharge.

The effect of CNS hyperactivity

ALconol. HEALTH & Itzsr-tecH WORLD

on brain function may be analo-gous to the effect of a flood ofincoming telephone calls on a tele-phone switchboardthe receipt ofincoming messages beyond theswitchboard's capacity causes thelines to cross and calls to becomedisconnected, placed on hold, orswitched to the wrong party. Asimilar "communications" snarlwithin the CNS translates into avariety of clinical results, depend-ing on the site in the nervous sys-tem where the seizure originates.Although many laymen think ofepilepsy as limited to the spectacu-iar general convulsions and black-outs of the tonic-clonic or grandh,a1 seizure, epilepsy also producessuch diverse phenomena as thesimple partial seizure in which thepatient is aware of the convulsionsand the nonconvulsive complexpartial seizure associated with hal-lucinations and memory lapses.

Virtually anyone may experiencean epileptic seizure, given the rightcombination of conditions. Accord-ing to Lennox (1960), individualsvary in their predisposition to sei-zures. For some people with a lowseizure threshold, in infection or amild head injury may be enough totrigger the occurrence of seizures.These individuals are most likely tobe diagnosed with primary epilepsy.Other people seem to have a highseizure threshold and are moreresistant to precipitating factors.The results of recent experimentsdemonstrate that at least some pre-disposition toward seizure is geneti-cally inherited--for example,scientists have selectively bredseizure-prone and seizure-resistantanimals (see, for example, Mishraet al. 1988). Other experiments havedemonstrated that seizures can beinitiated deliberately through a"kindling" process of CNS stimula-tion (see, for example, Mucha andPinel 1979 and Freeman 1981).

According to W. Allen Hauser,

M.D., professor of public healthand neurology at Columbia Univer-sity, the prevalence of epilepsy inthe general population ranges be-tween 6 and 10 cases per 1,000. Inother words, as many as 1 personper 100 experiences epileptic sei-zures sometime during his or herlife. Epilepsy is slightly more preva-lent among men than amongwomen, and more than one-half ofall cases involve onset after the 18thbirthday (Hauser 1988).

Neurologists divide epilepsy intotwo categories. Symptomatic epi-lepsy is associated with knownorigins, including tumors, infec-tions, and injury to the nervoussystem. Primary epilepsy has noclearly identifiable cause other thangenetic predisposition. Most casesof recurrent epileptic seizure involveprimary epilepsy.

In some instancesas in theexample of the overworked studentcited earliera specific seizureepisode can be associated with pre-cipitating conditions including sleepdeprivation or exposure to a flicker-ing light source. It is not clear,however, why the conditions thatprecipitate seizures differ amongseizure-prone people or why behav-ior as universal as the act of fallingasleep occasionally triggers convul-sions. Many aspects of primaryepilepsy remain a mystery.

ALCOHOL AND PRECIPITATIO

OF SEIZURE

Clinicians long have observed thatalcoholic beverages play a rule intriggering seizures (Buchan 1800;Gowers 1893). Seizures followingintoxication are known as "rumfits," "withdrawal seizures," or "al-coholic epilepsy," as distinguishedfrom primary epilepsy.

An estimated 20 to 25 percert ofnewly diagnosed adult cases ofepilepsy have no risk factors otherthan a history of alcohol abuse(Hauser et al. 1988). According to

Vol.. 13, Na 2.,1999

4,

Hillbom (1980), almost one-half of560 seizure patients admitted dur-ing 1 year to the emergency depart-ment of a hospital in Helsinki,Finland, had been intoxicatedwithin 12 hours of the incident.Similarly, a study of 566 patients ina detoxification unit in the UnitedStates showed that nearly one-thirdevidenced seizure symptoms at thetime of admission (Gerson andKarabell 1979).

CNS hyperactivity is involved inboth "alcoholic epilepsy" and pri-mary epilepsy. Nevertheless, clinicalstudies have demonstrated that thediagnostic tool known as an elec-troencephalograph (EEG) can dis-tinguish between the brain wavepatterns of epileptic patients and 90percent of all other patients admit-ted for alcohol-related seizures(Hauser et al. 1982; Deisenhammeret al. 1984; Vossler and Browne1988). This distinction and thefailure of most patients withalcohol-related seizures to developother epileptic svr Jilts suggestthat "rum fits" are different fromprimary epilepsy.

Findings on the prevalence of therelationship between alcohol useand seizures raise important scien-tific questions because beveragealcohol or ethanol is essentially aCNS depressant. In addition,ethanol has been perceived andoccasionally prescribed as an anti-convulsant. One therefore mightpostulate that alcohol reduces hy-peractivity and makes seizures lesslikely. For this reason, scientists andclinicians specializing in the ner-vous system are investigating thespecific mechanisms involved whenseizures are associatedabuse.

THE WITHDRAWAL HYPOTHESIS AT THE

1988 ALCOHOL AND SEIZURES

SYMPOSIUM

In September 1988, an internationalsymposium on alcohol and seizures

139

Epilepsy, Seizures, and Alcohol

was held in Arlington, Virginia,under joint sponsorship of theAmerican Epilepsy Society and theEpilepsy Foundation of America.Tiventy-nine distinguished speakersand 18 poste: session presentersfrom 7 countries exchanged re-search results and working hypothe-ses on the basic mechanisms andclinical management of alcohol-related seizure. Many of the de-scribed studies reflected NIAAA'ssupport of research exploring thepossible origins of alcohol-relatedseizure within the complex inter-action of the neuron with itsenvironment.

Ivan Diamond, NI.D., Ph.D.,professor of neurology at theUniversity of California at SanFrancisco, provided symposiumattendees with an overview of theissue (Diamond 1984. According toDiamond, most scientists believethat the phenomenon of withdrawalrather than the act of consumingthe drug alcohol itself is th.s primeculprit in alcohol-related seizures.Until recently, it was thought thatsuch phenomena as alcohol depen-dence, tolerance to the drug's ef-fects, and withdrawal take placeonly after long-term alcohol abuse.Recent experiments, however, indi-cate that these alcohol dependencephenomena may be observed at thecellular level following a singledrinking occasion. Such experimen-tal observations at the cellular levelmay explain why seizure phenom-ena, similar to those observed insome drug addicts who are experi-encing withdrawal, can occur fol-lowing an isolated drinking binge.

Diamond noted that the searchfor biochemical processes involvedin seizure generation during with-drawal from alcohol focuses onthree elements of the CNS. Somescientists are examining the mem-brane of the neuron itself for rapid

or long-term alterations associatedwith alcohol use. Others are exam-ining alcohol-related effects onneuron receptors and ion channelsnerve cell structures directly in-volved in receiving, transmitting,and inhibiting electrochemical im-pulses. A third group is investigat-ing the possibility that alcoholchanges the body's ability to main-tain a supply of nutrients to theneurons.

Diamond cautioned against as-suming that any seizures producedby withdrawal must be related tothe body's adaptation to alcohol.He reminded symposium attendeesthat withdrawal and associatedseizures alternatively may resultfrom CNS reaction to indirect ef-fects of alcohol consumption. Sup-port for Diamond's warning wasprovided in a presentation by JohnP.J. Pinel, Ph.D., professor ofpsychology at the University of

Experimentalobservations at thecellular level mayexplain why seizurephenomena . . . canoccur following anisolated drinkingbinge.

British Columbia (Pinel et al.1988). Pinel and colleagues studiedthe effects of administering alcoholprior to kindled (artificially in-duced) seizures compared with theeffects of administering alcoholfollowing seizures. Their findingsrevealed that timing of the adminis-tration of alcohol relative to theinducement of seizures was criticalto producing tolerance to the anti-

149

convulsant action of alcohol on thebody. Pinel concluded that thistolerance is an adaptation to one Ithe effects of alcohol on thebodythat is, the anticonvulsantactivity that prevents or dampensseizuresrather than an adaptationto alcohol's presence in the body.

Robert J De Lorenzo, M.D.,Ph.D., professor of neurology atthe Medical College of Virginia,summarized for symposium attend-ees the state of the art in searchingfor the cause of alcohol-relatedepileptic seizure at the level of theindividual neuron (De Lorenzo1988). Focusing his remarks onsuccess in observing alcohol-relatedchanges in neurotransmitterschemicals that activate neuronreceptors and ion channelsDe Lorenzo stated:

Mil neurobiology over the last 10years . . . we've gone from notexamining the role of neurotrans-mitters at all to ' v focus on theindividual neurotransmitter tooverall changes in the neurotrans-mission process. In effect, we'regoing from "the receptor of themonth" to deciding that every-thing is related to excitability. Wenow must look at unifying con-cepts: which observed changesmean something significant?When 50 [cellular] receptors [forneurotransmitters] change valuein response to alcohol with-drawal, does that mean that all50 are related to alcohol with-drawal or only that some of themare related?

Other symposium attendees agreedwith DeLorenzo's prescription ofintegrating separate research find-ings into unifying concepts. Theyacknowledged that years of worklie ahead in trying to determinewhich of the many observed CNSchanges following exposure to alco-

- - - ------------ALCOHOL HLALTH £ RJSLAICH WORLD

hol are most important in definingalcohol withdrawal at the cellularlevel and in explaining how with-drawal may precipitate seizures.

Is THE WITHDRAWAL HYPOTHESIS

Corm Ecr?

Within the past year, some re-searchers have challenged the as-sumption that alcohol withdrawal isthe mechanism responsible foralcohol-related seizure. One of themost sophisticated examinations ofthe alcohol withdrawal hypothesishas been presented by Stephen K.C.Ng, M.D., Ph.D., assistant profes-sor of public health and pediatrics,Ind his colleagues at ColumbiaUniversity. Using a combination ofclinical studies and statistical find-ings from computer modeling tech-niques, Ng and his colleaguesquestioned the validity of alcoholwithdrawal as the source of seizuresfor the following reasons:

The withdrawal hypothesis isincompatible with the drinkinghistory of most patients admittedfor alcohol-related seizures. Onlya minority of these patients hadreduced consumption sufficientlyto produce withdrawal prior tothe onset of seizures.Computer modeling found thatthe time lapse between cessationof drinking and onset of seizuresdid not suppol t the withdrawalhypothesis and that 16 percent ofalcohol-related seizures occurredafter 2 weeks of sobriety.Computer modeling found thatseizure onset was more likely tobe related to the level of drinkingthan to withdrawal (Ng et al.1988).

Ng and his colleagues raised thepossibility that alcohol has a dose-dependent relationship with seizuresand that seizures may result fromdirect toxic effects of the drug.

Although some clinicians support

the view that alcohol withdrawal isnot the culprit in alcohol-relatedseizure (Koppel et al. 1988), othersargue that more than one replica-tion of the Ns research is necessarybefore discarding the alcohol with-drawal explanation for alcohol-related seizure. Roger P. Simon,M.D., wrote in a recent editorial inThe New England Journal ofMedicine:

The issue of whether alcohol-related seizures are caused byalcohol itself or by alcohol with-drawal cannot be consideredsettled. . . . [T]hat seizuresoccur as a direct effect of alcoholuse and that they occur as a man-ifestation of alcohol withdrawalmay not be mutually exclusivepropositions (Simon 1988,p. 716).

%SYS FOR SEIZURE AMONG EPILEPTICS

WHO DRINK

Almost 50 years ago, Lennox (1941)affirmed that epileptic patients areneither more nor less likely thanother populations to abuse alcohol.Although comprehensive data areI- ...King, more recent surveys oftenconfirm that the drinking patternsof individuals with priraary epi-lepsy are similar to the prevailingdrinking patterns of their culture(Hoeppener et al. 1983). An excep-tion to this general rule is providedby Johnson (1985), who interviewedprimary epileptics in the Welling-ton, New Zealand, metropolitanarea. Johnson stated that 20 per-cent of epileptics reported drinkingthe equivalent of 80 grams or moreof pure ethanol per day comparedwith 6 percent of the general NewZealand population.

Studies of epileptics who occa-sionally drink alcoholic beveragesindicate that seizure occurrencemay be associated with their drink-ing. Mattson (1988) surveyed 112

Va. 13, Na 2, 190

Patients . . . whocontrol their seizuresthrough medicationshould be advised ofthe risks . . . fromthe indirect effects ofdrinking.

seizure-prone patients who usedalcohol at nonabusive levels andfound that 20 percent reportedsome increase in seizures "themorning after." Similarly, Johnson(1985) reported that 12 percent ofprimary epilepsy seizures "wereprobably precipitated by ethanol inpatients who could not be said tohave a major drinking problem."Controlled experiments conductedwith low doses of alcohol, however,have not verified any increase inseizure activity among patients withprimary epilepsy (Hauser et al.1988).

Epileptics who drink to intoxica-tion encounter higher risks, in partbecause of the indirect effects ofalcohol consumption on manage-ment of their condition. As notedby Simon (1988), an evening ofdrinking may provoke a seizurethrough alteration of the normalsleep routine. Intoxication mayresult in failure to maintain anti-convulsant medication used in thetreatment of epilepsy (Johnson1985). The interaction of alcoholwith drugs used in treating epilepsymay reduce the effectiveness ofmedication, increase the rate atwhich medication used by thebody, or produce potentially dan-gerous side effects. Finally, intoxi-cation is a major risk factor foraccidental injuries that may triggerepileptic seizures.

Should a physician counsel absti-

141

Epilepsy, Seizures, and Alcohol

nence to a patient with primaryepilepsy? In practice, a survey of asample of clinicians throughoutEurope conducted by th, EpilepsyCentre of the Netherlands iiidicatedthat national culture influences thetype of advice that is given: Physi-cians in wine-producing and -con-suming nations were less likely thanphysicians in northern Europe tourge Ipileptic patients to abstainfrom alcohol use (Hoeppener 1988).Daring informal discussions, Amer-ican physicians attending the inter-national symposium on alcohol andseizures were divided on the justifi-cation of complete abstinence forpatients with epilepsymany heldthe view that any additional risk forseizure or for reduced effectivenessof anticonvulsant medication isunacceptable.

At a minimum, patients withprimary epilepsy who control theirseizures through medication shouldbe advised of the risks to seizurecontrol from the indirect effects ofdrinking behavior, as cited bySimon (1988) and Johnson(1985). Patients also should bemonitored carefully for symptomsof alcohol abuse because of thepotentially serious consequencesof intoxication.

It may be wise for patients withprimary epilepsy to carry identifica-tion that would help hospitalemergency room staff to make anappropriate diagnosis. Althoughmost cases of alcohol-related sei-zure can be distinguished fromprimary epilepsy through the use ofan EEG and family history (Deisen-hammer et al. 1984), the pressuresof time and caseload may delaythese procedures '1 the emergencyroom setting. When a patient isunable to respond to family historyquestions, it is possible that clini-cians may prefer to withhold long-term anticonvulsant medication inthe belief that the convulsivepatient is displaying alcohol-

related seizure rather than pri-mary epilepsy.

REFERENCES

BucHAN.W. Domestic Medicine. 17th ed.London: A. Strahan, 1800.

DEISFNHAMMER, E.; KLINGER, D.; AND

TRAGNER, H. Epileptic seizures in alcoholismand diagnostic value of El',G after sleepdeprivation. Epilepsia 25:126-530, 1984.

DELoanNzc. R.I. "Models of Excitability:Receptors and Transmitters." Presentation tothe Panel on Basis, M....lianisms of Alcoholand Seizure, International Symposium onAlcohol and Seizures, Arlington, Virginia,September 29-30, 1988.

DIAMOND, I. "Models of Investigation ofSeizures Associated with Alcohol." Presen-tation to the Panel on Basic Mechanisms ofAlcohol and Seizures, International Sympo-sium on Alcohol and Seizures, Arlington,Virginia, September 29-30, 1988.

FREEMAN, F.G. Effects of ethanol on thedevelopment of kindled seizures in rat amyg-dala. Journal of Studies on Alcohol 42:500-507, 1981.

GERSON, I.M., AND KARABELL, S. The use ofelectroencephalogram in patients admittedfor alcohol abuse with seizures. ClinicalElectroencephalography 10:40-49, 1979.

GOWERS, W.R. A Manual of Diseases of theNervous System. Vol. 2. London: J & AChurchill, 1893.

HAUSER, W.A. "Alcohol and Epilepsy: TheFrequency of the Problem." Presentation tothe Panel on Clinical Overview, InternationalSymposium on Alcohol and Seizures,Arlington, Virginia, September 29-30, 1988

HAUSER, W.A.; NG, S.K.C.; AND BRUST,

J.C.M. Alcohol, seizures, ana epilepsy.Epilepsia 29(Suppl. 2):S66-S77, 1988.

HAUSER, W.A.; RICH. S.; NICOLOSI, A.; AND

ANDERSON, V.E. Electroencephalographicfindings in patients with ethanol withdrawalseizures. Electroencephalography and Clini-cal Neurophysiology 52:64, 1982.

HILLsom, M.E. Occurrence of cerebralseizures provoked by alcohol abuse. Epilcp-sia 21:459-466, 1980.

HOEPPENER. R.J. ; KUYER, A.; AND VAN DER

LUDT, P.J.M. Epilepsy and alcohol: TheInfluence of social alcohol intake on seizuresand treatment in epilepsy. Ep:!Posia 24.459-47!, 1983.

HOEPPENER. R.J. "The Effect of SocialAlcohol Use on Seizures in Patients withEpilepsy." Presentation to the Panel onClassification and Diagnosis of Syndromes,

142

International Symposium in Alcohol andSeizures, Arlington, V,.girna, September 29-30, 1988.

JOHNSON, R. Alcohol and fits. British Jour-nal of Addiction 80:227-232, 1985.

KOPPEL, B.; DARAS, M.; GROSSINGER, B.;

LIZARDI, E.; AND TUCHMAN, A. "Seizures inCity Hospital Alcoholic Patients." Unpub-lished paper presented in a poster session tothe International Symposium on Alcoholand Seizures, Arlington, Virginia, September29-30, 1988.

LENNiox, W.G. Alcohol and epilepsy. Quar-terly Journal of Studies on Alcohol 2:1-11,1941.

LENNOX, W.G. Epilepsy and Related Disor-ders. Boston: Little, Brown, & Co., 1960.

MATTSON. R. "Effect of Alcohol on Seizuresin Patients with Epilepsy." Presentation tothe Panel on Classification -aid Diagnosis ofSyndromes, International Symposium onAlcohol and Seizures, Arlington, Virginia,September 29-30, 1988.

MISHRA, P.K.; DAILEY, J.W.; REIOEL, C.E.;

AND JOBE, P.C. Brain norepinephnne andconvulsions in the genetically epilepsy-pronerat: Sex-dependent response to Ro 4-1284treatment. Life Sciences 42:1131-1137, 1988.

MUCHA, R.F., AND FINEL, J.P.J. Increased

susceptibility to kindled seizures following asingle injection of alcohol. Journal of Stud-ies on Alcohol 40:258-271, 1979.

NG, S.K.C.; HAUSER, W.A.; Bausr, J.C.M.;AND SUSSER, M. Alcohol consumption andwithdrawal in new-onset seizures. NewEngland Journal of Medicine 319:666-673,1988.

PINEL. J.P J ; MANA. M.; AND Ktm.C.K."Effect-Dependent Tolerance to Ethanol'sAnticonvulsant Effect on Kindled Seizures."

Presentation to the Panel on Basic Mecha-nisms of Alcohol and Seizure, InternationalSymposium on Alcohol and Seizures,Arlington, Virginia, September 29-30, 1988.

Sis46,4R.P. Alcohol and seizures. New En-gland Journal of Medicine 319:715-716,1988.

VICTOR, M., AND ADAMS, R.D. The effects ofalcohol on the nervous system. Proceedingsof the Association for Research in Nervousand Mental Disease 32:525-573, 1953.

VICTOR. M., AND BRAUSCH, C. The role ofabstinence in the genesis of alcoholic epi-lepsy. Eprlepsia 8:1-20, 196'.

VOSSLER, D., AND BROWNE, T.R. Absence of

EEG photoparoxysmal responses in alcoholwithdrawal patients treated with benzodiaz,e-pines. Neurology 38(Suppl. 1):404, 1988.

ALCOHOL. HEALTH & RESEARCH WORLD

)

The National Institute on Alcohol Abuse and Alcoholism,announces the public availability of

ETOHThe Alcohol and Alcohol Problems Science Database

NIAAA cordially invites you to preview the databaseat the Institute's Scientific Exhibit during the following events:

Annual Meeting of theNational Association of State

Alcohol and Drug Abuse DirectorsJune 3-7, 1989

Westin Cypress CreekFort Lauderdale, Florida

10th Annual Meeting of theResearch Society on Alcoholism

June 10- 15,1989Beaver Creek Resort

Vail, Colorado

97th Annual Convention of theAmerican Psychological Association

August 11-15, 1989New Orleans Convention Center

New Orleans, Louisiana

41t Annual Scientific Assembly of theAmerican Aeademy of Family Physician,

September 18-21, 1989Los Angeles Convention Center

Los Anc1,-s, California

1 17th Annual Meeting of theAmerican Public Health Association

October 22-26, 1989Chicago Hilton and Towers

Chicago, Illinois

Alcohol and OtherDrug Abuse by thePhysically ImpairedA Challenge for RehabilitationEducatorsBOBBY G. GREER, PH.D.

Alcohol and other drugabuse is a problemamong some clientswith physical impair-

ments (Anderson 1980-1981; Boos1980-1981; Greer 1986), althoughthe scope of the problem is notknown precisely (Hindman andWidem 1980-1981; Greer 1986).Thurer and Rogers (1984) foundthat 53 percent of a sample of phys-ically impaired clients rater' helpwith alcohol or other drug prob-lems as a "substantial need" or"great need" among the physicallyimpaired.

The lack of services to meet thisneed can be traced in part to thetraining received by rehabilitationcounselors, who often are taught toexpect that their future clients willhave only one disability. Whenmultiple disabilities are discussed inrehabilitation education, they usu-

BOBBY G. GREER, PH.D., is professorof Counseling and Personnel Serv-ices at Memphis State Universityand director of the vocational eval-uation unit. Comments should beaddressed to Professor Greer atMemphis State University, Mem-phis, Tennessee 38152.

144

ally are described in terms of suchpairings as brain injury with con-vulsive disorders, cerebral palsywith speech problems, and lowback injury with a learning disabil-ity. Physically impaired clients withalcohol or other drug problemsoften are described in training ma-terials as having one primary dis-ability and almost never as havinglong-term dependence on alcoholor other drugs.

This article examines possibleexplanations for the lack of discus-sion of alcohol and other drugproblems in most counselor trainingprograms. It also presents somestrategies to rectify this omission.

AN APPROPRIATE INTERVENTION ROLE

FOR REHABILITATION COUNSELORS

In the author's view, four generalguidelines on the appropriate roleof the rehabilitation counselor inintervention for alcohol and otherdrug abuse can be inferred from theethical standards and principles ofthe profession (as discussed in theaccompanying sidebar):

1) The rehabilitation counselorwho knows that a client abusesalcohol or other drugs, and thatthe abuse may interfere with the

T. 5 _.A.,'

University of Nevada

ALCOHOL. HEALTH & RESEARCH WORLD

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............,C, , .

...

VOL. 13, Na 2,1 US

A Challenge for Rehabilitation Educators

client's rehabilitation program,is professionally obligated tobring this fact to the client'sattention. The counselor shouldapprise the client of all availableintervention options.

2) The rehabilitation counselorshould make alcohol or otherdrug abuse intervention a partof the Individual Written Reha-bilitation Plan, if the clientconsents.

3) The client has a right to refuseany suggested intervention.

4) If the client refuses intervention

and if the client's persistentabuse of alcohol or other drugswill seriously impair potentialbenefits from rehabilitationservices, the counselor may ter-minate services to the client.Services should be terminatedonly after reasonable effort tosecure the client's compliancehas failed. Upon termination,the counselor is obligated torefer the client elsewhere.

The abuse of drugs prescribed bya physician is a specific area of

client drug abuse in which directconfrontation by the rehabilitationcounselor may not be indicated.Diazepam (Valium), for example,can be abused (Hepner et al. 1980-1981), and a counselor may havereason to believe that a client isreceiving and/or using diazepambeyond appronriate therapeuticlimits. In such situations, the coun-selor would, without delay, conferwith the rehabilitation agency'smedical consultant. If the patient isfound to be abusing a drug that isprescribed within therapeutic limits,

PROFESSIONAL ETHICS AND ALCOHOL AND DRUG ABUSE

IN REHABILITATION COUNSELING

"[low far should a rehabilita-tion counselor go in identify-

ing a client who has an alcohol orother drug abuse problem in addi-tion to ..me or more physical im-pairments? Some authors assertthat any intervention goes beyondappropriate roles and duties. Forexample, one of the major intro-ductory textbooks in vocationalrehabilitation states:Paternalism can often be con-fused with caring. What thecounselor knows is best for theclient can get in the way of truerespect of the client's autonomyand independence. If a clientwith emphysema, knowing fullwell the dangers of smoking,decides not to give up ciga-rettes, should the counselorrespect that decision or attemptto change it? If a client whoreceived a $.1 million settlementfrom the automobile accidentthat landed him in the rehabili.tation center decided to foregothe arduous task of extendedphysical and vocational rehabili-

tation, and be dependent in-stead, should the rehabilitationcounselor persistently encouragehim to "maximize his poten-tial?" The goal of "maldng"the client as independent aspossible contains inherent con-tradictions if the client is deni-dthe freedom to choose not to beindependent. Professional andmedical approaches towarddisabled persons emphasizechanging the client. Disabledpersons . . . are opposed toclient change as the primaryfocus (Rubin and Roessler 1987,pp. 117 -1881.

Although this concept compli-cates the answer to how far acounselor should go in dealingwith a client's abuse of alcohol orother drugs, there are ethicalstandards in the profession thatsupport an activist role. Onecanon incorporated in the Profes-sional Ethics for RehabilitationCounselors (National Council on

Rehabilitation Education 1988)states:

Rehabilitation counselors shallrespect the integrity and protectthe welfare of people anda. pups with whom they work.The primary obligation of reha-bilitation counselors is theirclients, defined as people withdisabilities who are directlyreceiving services from a reha-bilitation counselor . . (p. 67).

Since the ultimate objective of therehabilitation counselor is thetotal rehabilitation of the client,this canon implies that the coun-selor has a professional obligationto confront an alcoholic clientregarding the abuse and to de-velop a strategy for dealing withthe problem. When the counseloris responsible for the developmentof an Individual Written Rehabili-tation Plan (IWRP) for a clientwho abuses alcohol or otherdrugs, the intervention strategycan become an integral part of theIWRP.

BOBBY G. GREER, PH.D.

146ALCOHOL HEALTH & RESEARCH WOIU.D

the medical consultant, not thecounselor, would decide whataction to take. Similarly, if it issuspected that the client is receivinga larger than therapeutic dose of apsychoactive medication, the medi-cal consultant would intervene; thecounselor is bound by professionalethics to avoid confrontation withthe client on the issue of the prac-tices of the treating physician.

CURRICULUM ISSUES IN REHABILITATION

COUNSELOR EDUCATION

The traditional model for graduateprograms in rehabilitation counsel-ing was established in the mid-1950s(Wright 1980). Although aspects ofthis model still are debated, mostcurriculums closely resemble amodel proposed in 1956 (Graves etal. 1987; Wright 1987; Walker andMyers 1988). This course worktypically consists of 1) an introduc-tion to vocational rehabilitation,2) medical aspects of rehabilitation,3) psychosocial adjustment to dis-abling conditions, 4) assessments invocational rehabilitation, 5) coun-seling technique and practice,6) occupation information andcareer developrn 7) current top-ics in rehabnation w. taught asa seminar), 8) an internship experi-ence, and 9' electives.

As noted earlier, publicationsused in this curriculum tend toavoid the topic of multiple disabili-ties, including the pairing of physi-cal impairment with alcohol orother drug dependence. Only onetext on psychosocial adjustment todisability, for example, mentionsalcohol and other drug abuse (Vash1981). lino sign;ficant publicationsstand as exceptions to the generalrule of omitting alcohol and otherdrug abuse from teaching materialsused in the rehabilitation educationcurriculum. One of these is thecomputer-generated simulationprogram developed by Chubon

(1986). The other exception isbrief discussion of the impact ofalcohol and other drug problems onthe development of the rehabilita-tion plan for disabled clients incor-porated in the training materials forthe Preliminary Diagnostic Ques-tionnaire or PDQ (Moriarty 1982).The PDQ, a preliminary screeningtool, has two questions dealing withclient abuse of alcohol and otherdrugs.

To improve coverage of alcoholand other drug issues in rehabilita-tion counselor education, profes-sionals in the field need to addressthe paucity of literature on thistopic. Specific topics that may beincluded are definition of terms,epidemiology, social and familyeffects, client education needs,pharmacology and pathology, andlegal and ethical issues (NIAAA1985). Thc AID Bulletin,' a quar-terly newsletter about alcohol andother drug abuse among personswith disabilities, is particularlyuseful. Another potential resourceis the bibliography of materialsrelated specifically to alcohol andother drug abuse among thephrically/intellectually impairea,available from the National Clear-inghouse for Alcohol and DrugInfo.mation (NCADI 1987). Grad-uate students in rehabilitationcation should be encouraged tocontribute to the literature on alco-hol and other drug use among thedisabled by conducting research onthe topic.

Another necessary component ofcurriculum revision is the inclusion

' The AID Bulletin publishes feature articles,announcements, and notices of new pro-grams that would be helpful and informativefor both faculty and students rehabilita-tion counseling programs. The acronym AIDstands for Addiction Interventior. with theDisabled. Further information cn the AIDBulletin can be obtained from .'1..canderBoras, Ph.D., Department of Sociology,Kent State University, Kent, Ohio 44242.

Vol- 13, Na 2, 14119

of casework ex-?riences in existingcourses and fieldwork. Such experi-ences could be modeled after thosedeveloped for education in otherhealth professions (ADAMHA!986). This approach would incor-porate four basic elements:

integration of relevant alcoholand other drug abuse content intoexisting courses and seminarsinclusion of alcohol and other'rug abuse program facilities in

clinical experiences involvingpracticum and internship sitesexposure durin,Y fieldwork to suchself-help groups as AlcoholicsAnonymous, Al-Anon, and Nar-cotics Anonymousparticipation in client experiencesincluding role playing and video-taping (see Spickard et al. 1989)as well as exercises designed toclarify the students' own valuesconcerning alcohol and otherdrug use. These experiences alsocould include simulations de-signed to explore approaches toconfronting the manipulativeclient.

EDUCATION To DISPEL HARMFUL

ATTITUDES

The process of educating rehabilita-tion c, 'unselors on issues relating toalcohol ai,: ter drug abuseamong clients with physical impair-ments is complicated by the preva-lence of potentially harmfulattitudes and beliefs among coun-selors. tiAltudes that could be ad-dressed during the education ofrehabilitation counselors includethe following:

having expectations that are lowerthan they should be for clientswith alcohol-related problemsthe belief that "mourning" be-haviors or the lack of "normal-ity" justify client abuse ofalcohol

147

A Challenge for Rehabilitation Educators

misplaced sympathy that can bemanipulated by an alcohol abus-ing clientacceptance of abuse of alcohol orother drugs as the norm based onthe counselor's own problematicuse.

Iivo indei,endent studies (Allen etal. 1982; Goodyear . >83) have doc-umented a marked negative attitudeamong rehabilitation counselorstoward clients with alcohol-relatedproblems. One of the most omi-nous findings of both studies isthat many counselors consideredthe rehabilitation potential ofsuch clients to be minimal ornonexistent.

A second factor influencing per-ceptions of rehabilitation personneltoward alcohol or other d-ug abusebehavior is the "require' formour ling" identified by Wrigk'(1983). This "requirement" impliesthat persons with physical impair-ments are dewed by most nondis-abled individuals as being in a stateo: loss. In this state, the Hidividualis expected to "mourn" the loss byexhibiting such behaviors as denial,depression, and lack of motivation.Some nondisabled individuals in-clude alcohol or other drug abuseas a mourning behavior that maybe expected of a physically im-paired person.

Del oach and Greer (198i) iden-tify "deification of normality" as asimilar phenomeno: in which theabsence of impairment is perceivedby the nondisabled as the onlydesirable state of existence. Whenan indi 'dual adopts this rigidbelief, all manner of maladaptivebehaviorincluding alcohol andother drug abuseis justified bythe physically impaired client's lackof "normality." Awareness of analcohol problem in a disabled indi-vidual thus may ..)ke the reac-tion, "If I "ere that poor so-and-

14

The need to confrontstudent counselorsabout their attitudes. . . presents achcgenge torehabilitationeducators.

so, I would drink myself into obliv-ion too!"

Another confounding factor isthe ability of many disabled clientsto manipulate nondisabled personsand to play on their sympathy. Vash(1981) states that some tendencytoward manipulation is necessaryfor persons wi.h severe imps: .-rentsto function effectively. However,Cireer and colleagues (in press) citea case in which a disabled individ-ual applied much of his skill atgenerating sympathy to the procure-ment of drugs. Many nondisabledcounselors and counselor traineesview disabled personsespeciallythose disabled from birthas beingnaive, innocent, and free from thevices of so-called "normal" people.If a manipulative client works witha counselor who holds such anattitude, the results can be ex-tremely counterproductive.

The counselor's attitudes towardhis or her own me of alcohol orother drugs may further complicatethe issue. Because there are fewdata documenting the nature andprevalence of counselor attitudestoward alcohol and other drug use,data from other health professionsmay provide insight. The results ofrecent surveys ind:cate that as manyas 95 percent of medical studentsuse alcohol and 53 percent haveused other drugs (NIAAA 1985,p. 33). This same source indicatesthat 10 percent of such students

drink excessively. If the prevalenceof alcohol and other drug use issimilar among rehabilitation coun-selor trainees, it is possible thattheir attitudes toward alcohol orother drug use among their futureclients may tend to be permissive.

The need to confront studentcounselors about their attitudestoward alcohol or other drug usepresents a challenge to rehabilita-tion educators. Such student atti-tudes dry from condemnation ofany use of alcohol or other drugs topermissive tolerance of clearly ex-cessive use, with most counselors'attitudes falling somewhere betweenthese extremes. Either extreme iscounterproductive in interactingwith a disabled person who is abus-ing alcohol or other drugs.

An NIAAA curriculum guide foralcohol and other drug abuse edu-cation for pediatricians suggestsincluding in the curriculum a dis-cussion of the abusing health pro-fessional and the effects of suchabuse on the professional's judg-ment, lear,ng, decisions, and over-all professional productivitl(NIAAA 1985). Although this ap-proach could be adopted for reha-bilitation professionais, the NIAAAcurriculum guide notes that discus-sion of suc:1 issues in a courseformat tends to be "impersonal,generalized, or intellectualized"(P. 33).

Another workable solution to theproblem may be inviting students todiscuss with the instructor, outsideof class, their own concerns abouttheir use or abuse of alcohol andother drugs. Also, students withacademic or personal problems maybe provf ' .1 an opportunity to (-:-plore the possibility of alcohol orother drug use as a contributingfactor to these prelims.

Another apc roacn that may en-courage examination of attitudest.)ward alcohol and other drug use

is to supplement lass sessions withaud;nvisual material.. One cur-riculum for health professionals(Liepman et al. 1986) offers a com-prehensive appendix of videotapesana films designed to stimulatesuch exploration.

All student counselors need to beexposed to the issue of clients whoabuse alcohol or other drugs: Theprofession can do no less thanmake the effort to shape the viewsof future counselors according tofacts rather than myths about theissue.

REFERENCES

Alcohol, Drug Abuse and Mental HealthAdr nration (ADAMHA) ConsensusStateyents from the Conference on Alcohol,Drugs, and Primary Care Physician Educa-tion: Issues, Roles, and Responsibilities,November 12-15, 1905; Rancho Mirage,California. Fockville, Maryland: NationalInstitute on Alcohol Abuse and Alcoholism,1986.

ALLEN, H.A.; PETERSON, 1 ; AND KEATING. G

Attitudes t.. counselors toward the alcoholicRehabilitation Counseling Bulletin26(3):162-164, 1982

ANDERSON, P Alcoholism and le spinalcord disabled: A model program AlcoholHealth & Research World 5(2):37-41, ;980-1981.

BOROS, A. AILJ1,2;ISM intervention for thedeaf. Alcohol Health & Research World5_1:26-30, 1 -1981.

CHUBON. R A. Genesis II A computer-basedcase management simulation RehabilitationCounseling Bulletin 30(I):25-32, 1986

DELOACH, C P , AND GREER, B G. Adjustment

to Seveir Physical Disability. A Met4mor-phosis. New York McGraw-Hill, 1981

GOODYEAR, It Patterns of counselors' atti-tudes toward (inability groups Rehr,'" ihta-lion Counseling Bulletin 26(3) 181-186,1983

GRAVES, W.; COFFEY, D , HAFBCK. R., AND

STUDE, E NCRE position paper. Definitionof the qualified reh- oli,:qtion professionalRehabilitation Education 1(:):1-7, 1987

GREER, B.O Substance abuse among peoplewith disabilities: A problem of too muchaccessibility. Journal of Rehabilitation52:34-38, 1986.

GREER, B G , ROBERTS. R , AND MAY, G , EDS

A stt.dy of substance abuse in a vocationalevaluation samrile. Journal of Rehabilitation(in press)

HEPNLR, R.; KIRSCHRAUM, H ; AND LANDES, D

Counseling substam, abusers with addi-tional disabilities: The center for Indepen-dent living. Alcohol Health & ResearchWorld 5(2) 11-15, 1980-1981.

HINDMAN, M , ANL) WIDEM, P Special issue.

The multidisabled. Alcohol Health & Re-search World 5(2):5-10, 1980-1981.

LIEPMAN, M.R , ANDERSON, R C.; ANDFISHER, W., EDS Family Medicine Curricu-lum Glad- to Substance Abuse. Kansas City,MO: The Society of Teachers of FamilyMedicine, 1986.

MoiciAirry, I B. Raining Manual for theAdministration of the Prelim:T. iry Diagnos-tic Questionnaire. Morgantown, WV WestVirginia Rehabilitation Training Institute,1982.

National Clearinghouse for Alcohol andDrug Information (NCADI). NCADI Up-date Alcohol and Other Drugs and thePhystrallyantellectually-impaired. Rock-ville, MD he Clearinghouse, 1987.

National Council on Rehabilitation Educa-tion. Code of professional ethics for rehabil-itation counselors. Rehabilitation Education2(1) 65-74, 1988.

National Institute on Alcohol Abuse andAlcoholism, Pediatric Minimal Knowledgeand Skills. The First Step in Developing aCurriculum in Alcohol and Other Drugs forPediatricians DHHS Pub. No (ADM)281-85 -0014 Rockville, MD: the Institute, 1985.

RUBIN, S E , AND ROESSLER, R.T. Foundations

of the Vocational Rehabilitation Process 3ded Austin, TX. Pro-Ed, 1987

SPICKARD, A , JOHNSON, N.P.; AND BURGER, C

Learning through experience. Interviewingreal(?) patients. Alcohol Health & ResearchWorld 13:36-39, 1989

THURER, S., AND Roc .5. E.S. The mentalhealth needs of physically disabled persons:Their perspective. Rehabilitation Psychology29(4):239-248, 1984.

VASH. C L. The Psychology of Disability.New York- Springer Publishing, 1981.

WALKER. M ,L., AND MYERS, R W A counter-proposal: Definer- the qualified rehabilita-tion professional. Rehabilitation Education2(1):49-57, 1986.

WRIGHT, B Physical Disability: A Psycho-logical Appioach New York: Harper & Row,1983

WRIGHT. G.N Total Rehabilitation. NewYork Little, Brown and Company, 1980.

WRIGHT, G.N., ED Special Issue: Research onprofessional rehabilitation competenciesRehabilitation Counseling Bulletin3I(2):1987

New from NIAAAALCOHOL AND COGNITIONA Summary of Findings on the RelationshipBetween Alcohol and Cognitive Impaient

Chronic heavy drinking adversely affects the brain. Alcohol-inducedcognitive impairment may detract from the potential benefits of treatmentfor many patients.

Read about this treatment concern in the most recent Alcohol Alertbulletin, "Alcohol and Cognition," wliich addresses.

Cognitive impaethent in the first weeks of abstinenceExcessive alcohol use and malnutrition as possible contributorsto cognitive deficiencyCognitive impairment reversibilityIdentifying cognitive deficiency and tailoring treatment to the individual

Alcohol Alert is a timely information bulletin that relates research findingsto the practical concerns of clinicians and other ticatment professionals. Toreceive "Alcohol and Cognition" and future Alcohol Alert bulletins, sendyour name and address to Alcohol Alert Update, c/o CSR, Inc., Suite 600,1400 Eye Street, N.W , Washington, D.C. 20(X)5

VOL. 13, Ni 2, 19119 149

Results of a ModelIntervention Program forPhysically Impaired PersonsSHARON SCHASCHL, R.N., B.S.N., ANDDENNIS STRAW, C.C.D.P.

For many persons withdisabilities, alcohol andother drug dependenceimpc,.es far greater limita-

tions than their physical impair-ment. The problems created byalcoaol and other drug dependencefrequently are attributed tc thephysical impairment, and a ,treatdeal of time, energy, and moneymay be spent treating the "syrti;,-toms" rather than the disease ofdependence. Failure to addressalcohol and other drug dependenceadequately may prevent successfulrehabilitation and adjustment todisability, lead to increased medicalcomplications of the physical im-pairment, and interfere with prog-ress toward independent living.For this reason, disabled personsrequire access to alcohol and otherdrug abuse prevention efforts andto early alcohol and other drug

SHARON SCHASCHL, R.N., B.S.N., isprogram coordinator of the Chemi-cal Dependency/Physical DisabilityProgram at Abbott NorthwesternHospital/Sister Kenny Institute anda CertiPd Chemical DependencyPractitione- DENNIS STRAW,C. C. D. P, consultant to the pro-gram. Comments may be addressedto either coauthor at the AbbottNorthwestern Hospital ChemicalDependency Theatment Ce,iter, 18001st Avenue South, Minneapolis,Minnesota 5403.

150

dependence evaluation, interven-tion, and treatment.

OBSERVATIONS ON PERPETUATING

FACTORS

Factors that perpetuate alcohol andother drug dependence amongthose with physical impairmentsinclude the negative attitudes thatother people exhibit toward bothphysical impairment and alcoholand other drug dependence, thescarcity of knowledge and skills totreat the dual problems of alcoholand other drug dependence andphysical impairment, and the scar-city of specialized treatment pro-grams for this group.

Among these, the negative atti-tudes commonly held toward bothphysical impairment and alcoholand other drug dependence may bethe most difficult to overcome.Physically impaired persons oftenare perceived as hopeless, helpless,tragile, and sick. "'Physical impair-ment" is commonly equated with"illness," fostering the beliefs thatphysically impaired persons areincapable of assuming responsibil-ity for themselves, require repeatedhospitalizations, and must dependon medication to function.

In addition, a person who isphysically impaired may face addedstigma and may not receive helpthat is needed because he or she,Iso is abusing alcohol and/orother drugs. Sometimes, health careproviders and counselors, and alsc

family and friends, don't acknowl-edge or address the impaired per-son's use of alcohol and otherd7ugs. Well-meaning caretakers andloved ones may even encourage useof alcohol and other drugs due tothe misperception that the alcoholhelps the impaired person to social-ize, to experience pleasure or happi-ness, and possibly even to feel"equal" with more able-bodiedpeople. These well-meaning care-takers may even see that alcoholand oth,r drug abuse is self-destructive, but they don't want todeny the disabled person the indi-vidual "right" to elect to use thealcohol and other drugs.

There is often an erroneous as-sumption that all of the problemsexperienced by people with physicalimpairments are rel%ted p.imarilyto the impairment. Yet, personswho are abusing alcohol and otherdrugs whether physically impairedar notfanction well below theirpotential and may experience prob-lems in any or all of the followingareas of their lives: physical, emo-tional, spiritual, social, sexual,family relationships, legal, voca-tional, and financial. These prob-lems may be manifested by frequenthealth problems and/or hospitaliza-tions, low self-est ., poorpersonal hygiene, uependentlifestyle/living arrangements, asso-ciation primarily with alcohol andother drug users lack of motiva-tion, significant personality

ALCGHOL HELTH & RESEARCH WORLD

changes, memory deficits, depres-sion, rejection, of beliefs that oncewere important, isolation fromfamily and friends, and Involve-ment in unhealthy relationships.The affected person may become avictim or a perpetrator of sexualabuse or inappropriate sexualbehavior, suicide attempts, arrests,incarceration, loss of driver's li-cense or public transportation privi-leges, unemp'oyment, failure inschool, and lack of vocational in-volvement and may have difficultymeeting basic financial obligations.Problems and events such as thesemay be attributed to the physicalimpairment, when in fact alcoholand other drug use may be a signif-icant contributing factor.

Recognizing all of the factorsthat perpetuate alcohol and otherdrug dependence among those withphysical impairmentsthe conse-quences of negative attitudes com-bined with the lack of knowledge,skills, and specialized treatmentapproachescalls out for the devel-opment of model interventionprograms.

A MODEL INTRaViNTION PROGRAM FOR

PHYSICALLY hIPAHUID PERSONS

In 1983, Abbott NorthwesternHospital/Sister Kenny Institute inMinneapolis, Minnesota, imple-mented the Chemical Dependency/Physical Disability Program,designed to meet the specializedneeds of physically impaired per-sons. The program staff membersinclude a program coordinator, whois a Certified Chemical DependencyPractitioner (CCDP) and an experi-enced physical rehabilitation nurse,and a program consultant, who is aCCDP and is disabled and recover-ing from alcohol and other drugdependency. The work of the pro-gram staff affects three distinctareas: the Minneapolis community,the physical rehabilitation units andChron; Pain Rehabilitation Pro-gram at Sister Kenny Institute, and

VOL. 13, Na 2, 19119

Abbott Northwestern Hospital'salcohol and other drug dependencetreatment center.

Pi the community, alcohol andother drug dependence treatmentstaff of Abbott Northwestern Hos-pital conduct workshops to increaawareness and to provide directionin identifying and referring physi-cally impaired clients with alcoholor other drt.6 dependence. Thestaff members also provic...- consul-tation for community programdevelopment.

On the physical rehabilitationunits and in the Chronic Pain Reha-bilitation Program at AbbottNorthwestern Hospital/SisterKenny Institute, members of theprogram staff provide evaluationsof alcohol and other drug depen-dency for patients and consultationand education for patients, staffand families of patients.

In the alcohol and other drugdept.adence treatment center,members of the program staffcoordinate a physical disabilitycomponent integrated with AbbottNorthwestern Hospital's establishedChemical Dependency TreatmentProgram. The premise for establish-ing the disability component is thatthe clients may have unresolvedsocial, psychological, and medicalproblems associated with theirphysical impairments and that theseproblems need to be addressed tofacilitate treatment of continuedalcohol or other drug dependence.

Physically impaired patients nowcomprise 5 to 10 percent of thetotal patient population in the alco-hol and other drug dependencetreatment center. Patients withphysical impairments are expectedto participate with able-bodiedpatients in all scheduled programactivities. Program adaptationshave been made to accommodatephysical limitations to assure fullparticipation. For those patientsrequiring personal care services,Abbott Northwestern Hospital's

home health care agency schedulescertified nursing assistants for 2- to3-hour periods in the morning andevening. Nursing care, treatments,medications, and any Additionalassistance throughout the day areprovided by the regular nursingstaff members. Physical therapyand occupational therapy are or-de7ed only if necessary to maintainthe patient's level of functioning.

The Chemical Dependency/Physical Disability Program coordi-nator and program consultantprovide individual counseling andsupport to patients and their fami-lies for physical impairment anddependency issues and, with twoother professionals, lead a weeklypeer support group for recoveringphysically impaired persons. Thestaff of the Chemical Dependency/Physical Disability Program offersassistance to counseling and medi-cal staff to address the problems ofphysical impairment in the contextof treating the primary illness ofalcohol and other drug dependency.Program staff members also assistin formulating aftercare plans thataddress needs of physically im-paired, alcohol-dependent clients.The program staff members areavailable for followup consulta-tions, education, and awarenesstraining to reintegrate the 1...ysi-cally impaired person into thecommunity.

An important element of theChemical Dependency/PhysicalDisability Program is the weeklysupport group led by four profes-sionals who are experienced incounseling those with alcohol andother drug dependency as well asphysical impairments. The groupfirst met in August 1983 with onemember and three facilitators. At-tendance steadily increased and aconsistent weekly attendance of 20participants has been maintainedover the past year. There currentlyare 17 active core members, 6 ofwhom received treatment at other

151

Model Intervention Program

facilities. Length of membershipranges from 2 months to 3 years.Sobriety represented is 2 months to13 years. Although nearly 50 per-cent of the members are between 30and 40 years old, the age range ofthe group is from 20 to 60 years,with an average of approximately34 years.

The group generates discussionabout disability Issues that do notapply for regular treatment groupmeetings. Each member is encour-aged to relate personal concerns.The peer support Ild diverse expe-rience of the group members pro-vide fertile ground for personalgrowth and creative thinking asmembers begin to integrate into anable-bodied society.

DEMOGRA"HY AND ONSET

CHARACTERISTICS OF THE PATIENT

POPULATION

An analysis by primary diagnosis ofthe patients admitted to the Chemi-

cal Dependency/Physical DisabilityProgram from its inception throughearly 1988 revealed that three pri-mary diagnosesspinal cord injury,brain injury, and chronic painaccounted for more than one-halfof all diagnoses. Spinal cord injurywas the most prevalent, represent-ing one-fourth of the sampk. Incontrast, patients with sensory im-pairment accounted for less than 7percent of the total number of pa-tients admitted. Persons with hear-ing impairments usually are referredto other specialized programs.

There is a widespread belief thatphysical impairment causes alcoholand other drug dependency. Forpersons whose disabilities were theresult of a traumatic injury, severalstudies (Anderson 1980-1981;O'Donnell et al. 1981-1982;Sweeney and Foote 1982; Heine-mann 1986) indicate that the major-ity were involved in alcohol- orother drug-related accidents and

were experiencing problems relatedto their alcohol and other drug uselong before the onset of their physi-cal impairment. As shown in Figurel, statistics from the first 5 years ofthe program indicate that, of the 88clients with onset of disability afterthe 10th birthday, 72 clients (80percent) were dependent on alcoholor other drugs prior to the onset oftheir disability. Alcohol or otherdrugs contributed to the disablinginjury or illness of f ,ents (73percent of all client vith later on-set disability).

Among the 24 patients in theprogram who were congenitallydisabled and dependent on alcoholor other drugs, the majority hadbeen receiving prescribed medica-tions with mood-altering effectssince childhood and lived in pro-tective environments in which theiralcohol and other drug use wascontrolled and external stressorswere minimized. When these pa-

a.

04-

152 ALCOHOL HEALTH & RESEARCH WORLD

tients left the home environmentand attempted to enter fully into anable-bodied society, external stres-sors increased. They may have in-creased their alcohol or other druguse in an attempt to cope with theincreased stress.

The majority of the programparticipants have become depen-dent on alcohol, usually in combi-nation with marijuana or otherillicit drugs. Prescription medica-tions frequently are used as well.

OUTCOMES: THE CRUCIAL ROLE OF THE

SUPPORT GROUP

3ed on successful followup of 69patients admitted through February1988, there appears to be a directcorrelation between those personswho stay active in the disabilitysupport group and those who re-port complete abstinence fromalcohol and unprescribed drugs fora minimum of 6 months after ad-mission (see Figure 2). The follow-

up rate of 62 percent admittecly islow, but results obtained from self-reports of former clients are con-sistent v.' h observations gleanedfrom leading group sessions in theChemical Dependency/PhysicalDisability Program.

PhysLally impaired patients o.ten resist participating in the group,and most have had to be requiredto attend initially. Denial is evidentwhen severely disabled patientsrefuse to attend the group, stating,"I've already adjusted to my dis-ability," "I'm not like those people,""It depresses me to be around thosepeople,' or "Wnat right do youhave to label me 'disabled'?" Thosepersons who do readily attend thegroup for the first time frequentlyexpect support for use of alcoholand other drugs; they expect othersto "understand" that their physicalimmirment "justifies" their use ofalcohol and other thugs. Thesepatients are often disappointed and

Figure 2 easrapsolassiallalimmellas illis-41111+at di impart Snow,

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Vol.. 13, Na 2, 19$9

frustrated when, in contrast to theirexpectations, they find understand-ing of their feelings relating to theirphysical impairment and supportfor achieving a lifestyle free of alco-hol and other drugs. Commitmentto the program comes with partici-pating in the grolp and beingwilling to address the physical im-pairment and beginning to identifywith the group as whole.

Those persons who choose toremain free of alcohol and otherdrugs and to become actively in-volved in a recovery program gainself-esteem and self-responsibilityand begin the process of acceptingtheir disabilities. They are experi-encing better health and developingalternative means of managingchronic pain, sleep disorders, spas-ticity, and stress. New social experi-ences are replacing isolation, andhealthy relationships are replacingabusive, dependent ones. Many aredeveloping more independentlifestyles/living situations, are be-coming involved in vocational-avocational activities, and areresolving financial and legaldifficulties.

The first 5 years of our programhave been a formidable challengeand tremendous learning experi-ence. We would like to thank thosepersors who have allowed us to bea part of their recoveries.

REFERENCES

ANDERSON, P Alcoholism and the spinalcord disabled. A model program AlcoholHealth & Research World 5(2) 37-41, 1980-1981.

HEINEMANN, A W Substance abuse anddisability An update. Rehatnlital, in ReportJune3-5, 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 AlcoholHealth & Research World 6(2) 27-29, 1981-1982

SWEENEN. TT., AND FOOTE, J.E Treatment ofdrug and alcohol abuse in spinal cord injuryveterans Intgrnatwaul Journal of the Addic-tions ' n5).897-954, 1982

153

JOHN DE MIRANDA, ED M.,

AND LINDA CHERRY

154

`I ornia es ondsChanging Treatment SystemsThrough Advocacyfor the Disabled

dvocates for institu-tional change can havea major effect on pro-gum accessibility and

the creation of quality alcohol anddrug abuse services :1,1- personswith disabilities. Although institu-tionalized treatment sysi ems oftenappear lethargi: in r:,,N.Iting theneeds of the physically impaired,such systems can be invigoratedthrough a process of activism, doc-umentation of existing problems,

f;

Advocates of institutional change fogphysically impaired persons with alcoholand other drug problems have had asignificant impact on local services andState policy in California during the past 10years

and education. Events in Californiaduring the past 10 years demon-strate how individuals workingthrough coalitions at the cemmu-nity level can have significant im-pact on local services and Statepolicy.

THE DISAFILITY SUBSTANCE ABUSE

TASK FORCE

The acknowledged patriarch of thealcohol, drug, and disability move-ment in California is Pete Ander-

ALCOHOL HEALTH & RESEARCH WORLD

son. While working in the VeteransAdministration (VA) hospital sys-tem during the 1970s, Andersonbecame concerned about the dis-abled veterans who experiencedserious, unaddressed problems withalcohol and other drugs. His uneas-iness with the status quo extendedto the publicly funded recoverysystem, wnich then appeared to belargely unaware of the needs ofpersons with mobility and sensoryimpairments. Anderson's frustra-tion was fueled by difficulties heencountered in attempting to con-vince both the VA and the Califor-nia Department of Alcohol andDrug Problems that services weregrossly inaccessible to this commu-nity. He recalls:

It was a struggle to bring in AAand NA [Alcoholics Anonymousand Narcotics Anonymous]. Theprofessional staff were very reluc-tant to introduce significantchange into the program becausechange involved risk-taking.. . . Similarly, patients were notreally encouraged to leave thefacility and to learn to live in thecommunity. The program's exter-nal activities might include "roll-ing" across the street to a store ofa once-a-week bus excursion to amuseum. I was considered a tron-blemaker because I believed thepatients ought to be living in thecommunity and taking a busonce a week to visit the hospital!(personal communication,September 1, 1988)

JOHN DE MIRANDA. ED M., is direct9rof the California Alcohol, Drug,and Disability Study. LINDA CHERRYis director of the Bay Area Projecton Disability and Chemical Depen-dency. Comments should be ad-dressed to the authors at PeninsulaHealth Concepts, 2165 Bunker HillDrive, San Mateo, California94402.

Vol. 13, Na 2, 1989

To remedy what he saw as theunjust exclusion from alcohol anddrug abuse services of people withdisabilities, Anderson and othersfounded the Disability SubstanceAbuse lb_sk Force. He and AlanLowenthal, associate professor ofcommunity psychology at Califor-nia State University-Long Beach,also established programs atLowenthal's institution to provideeducational workshops, technicalassistance, and legislative advocacy(Lowenthal and Anderson 1980-1981).

Lacking significant funding, theDisability Substance Abuse TaskForce initially relied on the volun-teer efforts of its membership, in-kind donations from community-based programs, and occasionalgovernment support. Andersondescribes this period as the "touch-and-go years" because of the diffi-culties encountered in sustaininginterest in the issue. The problemswere exacerbated by the lack ofwidespread awareness of the provi-sions of section 504 of the Reha-bilitation Act of 1973 amongcommunity-based alcohol treatmentprograms. This legislation statesthat individuals cannot be deniedadmission to a federally fundedprogram on the basis of a disability.Full compliance often requires con-siderable financial expenditure forarchitectural modifications, com-

ixation devices, sign languageinterpreters, and other resources.

These initial difficulties graduallywere overcome during the 1980s,and the Disability Substance AbuseTask Forcesince renamed theCongress on Chemical Dependencyand Disabilityis now an effectiveadvocate for accessibility of treat-ment services throughout southernCalifornia. In part through theefforts of the coalition, the LosAngeles County Office of AlcoholPrograms, one of the largest pur-

chasers of treatment services in theNation, recently required all newprograms to be fully accessible topersons with physical impairments(County of Los Angeles 1988). AllLos Angeles County alcohol servicedelivery contracts now include spe-cific language mandating that eachprogram prepare and annually up-date a plan for increasing the acces-sibility of its services to disabledpersons. These plans must include aseparate report on services to hear-ing impaired clients. In addition,all programs funded by Los AngelesCounty must maintain participant72!ictration forms that include iden-tification of clients with disabilitiesother than alcoholism, includingsensory and mobility impairment,developmental disabilities, andmentally disabling conditions.

In 1987, neighboring OrangeCounty convened a Disabled AccessCoordinating Committee to ensurealcohol treatment program compli-ance with section 504 of the Reha-bilitation Act of 1973. Activities ofthe committee included a needsassessment and facilities survey thatproduced a series of recommenda-tions to improve access_ litythroughout the alcohol abuse ser-vices system. Susan Zepeda Ph.D.,deputy director of county alcohol-ism services, notes that the commit-tee's recommendation to develop asouthern California regional data-base of disabled service recipients isa first step toward the creation ofregional services:

In this age of fewer dollars, it'sdifficult for one county to sup-port a special residential programfor the deaf [client with alcoholproblems], for example. How-ever, when a consortium ofcounties cooperates and poolsresource, ,t becomes quite feasi-ble to create reality from ourdreams (personal communica-tion, September 20, 1988).

15!

California Responds

CDCD AND 'ME BAY AREA PROJECT

Inspired by Anderson's example,Jim Bouquin, director of the Dis-ability Resource Center at StanfordUniversity, organit.ed an ad hocvolunteer task force in the SanFrancisco Bay area. Bouquin hopedto create a nztwork of individualsand agencies that would documentthe need for appropriate treatmentservices for the disabled in the areaand otherwise reinforce the percep-tion that ch-mge was needed. Theresulting northern California coun-terpart to the Disability SubstanceAbuse Task Force is known as theCoalition on Disability and Chemi-cal Disability (CDCD).

With financial support from twolocal foundations anu a countygovernment, CDCD and a localindependent living center under-took d year-long effort in threecounties, known as the Bay AreaProject on Disabilities and Chemi-cal Dependency, to document theincidence and prevalence of alcoholand other drug proh:ems amohgadults with disabilities within ametropolitan population of morethan 2 million. During the springand summer of 1988, the bay AreaProject survey of public-sector alco-hol and other drug abuse serviceagencies received responses from 60percent of the identified potentialrespondents; 54 percent of identi-fiod disability service agencies alsoresponded to the survey. Among thesurvey findings reported by Cherry(1988) were the following:

Of the survey area's estimated62,927 individuals with disabili-ties who may have experienced aproblem with alcohol or otherdrugs, only 334 (0.53 percent)were served by the respondingagencies during the most recentreporting year.Sign language interpreters wereavailable in only 13 percent of theresponding alcohol and otherdrug service programs.

156

Up to 50 percent of respondingalcohol and other drag serviceprograms prohibited use of oneor more medications required forcontrol of a physical disability.Among responding disabilityservice agencies, only 17 percentconducted the equivalent of anin-depth assessment of alcoholand other drug use during theintake process.Only 15 percent of respondingdisability service agencies offeredinformation on alcohol and otherdrug abuse to their clients.

A second objective of the BayArea Project was to provide techni-cal assistance that encourages crea-tive coordination, cross-trainingbetween professional staff from thealcohol and other drug fields andthe disability professionals, andnetworking among alcohol, drug,and disability programs (CDCD1988). In response to a need citedby many teachers of special educa-, n, the Bay Area Project alsosupported plans to develop targetedprevention materials for use withdisabled young people who may beat high risk for developing alcoholand other drug dependencies.

The Bay Area Project culminatedin a conference that included con-current cross-training sessions,

county caucuses to nurture thedevelopment of local advocacyinitiatives, and workshops focusingon alcohol and other drug abuseprevention among young peoplewit'i disabilities. Unexpectedly, theBay Area Project ke.o generated atremendous outpouring of supportand curiosity among professionals,clients, and government officials.Among those expressing an interestwere peop.e with so-called "hiddendisabilities," such as epilepsy andmilder forms of mobility and sen-sory impairment. A second year offunding now is being sought forprojects derived from the Bay AreaProject's final recommendations.

THE CALIFORNIA ALCOHOL. DRUk., AND

DISABILITY STUDY

The State of California recentlycharged a special permanent over-sight commission to investigatecriticism that the State Departmentof Alcohol and Drug Programs hasnot provided adequate services forthe disabled. In 1987, the commis-sion convened a public hearing forthe purpose of ". . . determiningif methods of enforcing the currentFederal and State mandates forprogram access and non-discrim-ination are effective, identifyingthe size of the disabled, alcohol-abusing population, and determin-.011

Figural Promo ral INr1f1o>0oo>rl Ohio'( by AlJihe., for the1111. Nam Allsoltai. owl Other Brugarlsted Problem

Perceived Social Injustice

System Advocacya

External Documentation(The Bay Area Project)

Internal Documentation(CALADDS)

Consensusa

System Change

6 ,ALCOHOL. HEALTH & RESEARCH WORLD

ing if there are adequate methodsof coordinating information andreferrals to ensure the delivery ofservices" (N. Shappell, personalcommunication, May 1987).

In its report to the Governor(N. Shappell, personal communica-tion, May 1987), the commissionasserted that alcohol and otherdrug abuse among people withdisabilities is more widespread thanis commonly believed. Althoughthe commission acknowledged that

lifornia has enacted ample legis-lath:. designed to ensure access topublicly fvrid.?,d programs and facil-ities by the disabled, the reportindicated that neither the letter northe spirit of these laws has beenhonored. As a result, the commis-sion reported that there may be500,000 disabled Californians withalcohol- or other drug-related im-pairment who are unable to obtaintreatment.

Responding to these alleged defi-ciencies, the California Depark inz.ntof Alcohol and Drug Programscontracted with the Coalition onDisability and Chernkm1 Depen-dency to undertake an assessmentof treatment needs among Califor-nians with disabilities. This I-yearproject, the California Alcohol,Drug, and Disability Study(CALADDS), is a joint effort ofexperts from the fields of disability,alcohol and other drug service de-livery, survey research methodology,and service delivery to hearing-impaired and developmentally dis-abled persons.

CALADDS focuses on accuratelydocumenting architectural, attitudi-nal, and institutional barriers torecovery, primarily for individualswith mobility or sensory impair-ment. The re :.earchers also are in-vestigating and documenting theneeds of the developmentally chal-lenged and the mentally drabledwith dual diagnoses. The studyfindings will be reported to theDepartment of Alcohol and Drug

Vot. 13, No. 2, 191

Programs during the summer of1989. At tins writing, it is expectedthat the final report will includerecommendations to improve andexpand alcohol and other drugtreatment and prevention servicesstatewide.

The core of the CALADDSneeds assessment and documenta-tion process is a series of key in-formant surveys of disability serviceprograms throughout the St ate.Program directors have been askedto describe the alcohol and otherdrug problems of their clients. in-cluding difficulties experienced ininteracting with alcohol and otherdrug abuse recovery services. ASubset of agencies has been selectedto administer a questionnaire di-rectls' to clients that will generatedata about levels of alcohol andether drug use, experiences in ac-cessing recovery programs, and theperceived relationship between alco-hol and other drug use and thedevelopment of disability.

CALADDS also includes anunusual "street outreach" compo-nent that will attempt to determinethe needs of homeless disabledindividuals who experience alcoholor other drug problems. Feld-workers operating in selected urbanareas will conduct structured inter-views with homeless disabled peo-ple to provide data useful for thedesign of specific approaches toserve this population.

THE PROCESS OF STATEWIDE

INSTITUTIONAL CHANGE.

Jim Bouquin, founder and presi-dent of the CDCD, recently sug-gested a diagram that outlines theprocess followed by advocates ofinstitutional change for disabledpersons with alcohol and otherdrug problems (see Figure I). InCalifornia, the process began witha few individuals who perceivedinequity in access to recovery ser-vices. Organizing and collaboratingto Increase awareness and to edu-

t

cate professionals in alcohol andother drug abuse treatment resultedin a network of advocates with'nthe service delivery system. To j is-tify institutional change, however,policymakers needed concrete docu-mentation of the scope of the prob-lem and the potential need forservices. Initially, advocates andphilanthropies volunteered to pro-vide re,ources for documentation.These resources generated the datathat were used extensively in thefindings of the State oversight com-mission. In response to these find-ings, the State Department ofAlcohol and Drug Programs com-missioned CALADDS, a studywhose resources come from thepublic sector.

The next step, following "inter-nal" documentation of needs byCAL ADDS, may be to developconsensus among advocates andpolicymakers on the nature of thechanges that will improve access. Itis hoped that this consensus willlead to implementation r 'stemchanges that will make the alcoholand other drug abuse service systemaccessible to individuals withdisabilities.

REFERENCES

CIILRRY, L. Final Report Bay Area Projecton Disabilities and Chemical Dependency.San Mateo Coalition on Disability andChemical Dependency, 1988.

Coalition on Disability and Chemical Dis-ability The Seed Newsletter San Mateo theCoalition, 1988.

County of Los Angeles, Department ofHealth Services, Office of Alcohol Pro-grams 1987-88 Los Angeles County Planfor Alcohol-Related Services ,os Angelesthe County, 1988

LA/WI N'HAI . A , AND ANDI RSON, P Networkdevelopment Linking the disabled commu-nity to alcoholism and drug abuse programs4lcohol Health & Research 14-brld 5(2) 18-21,1980-1981.

SHAPE .I i , N Correspondence to the Hon.George Deukmejian, Governor of Califor-ma, from the Commission on CaliforniaState Government Organization and Econ-omy, May 1987

157

EPIDEMIOLOGIC BULLETIN NO. 21

Alcohol-Related MorbidityAmong the DisabledThe 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,alcohol-related problemsamong the physically im-paired have been largely

ignored. The problems of alcoholand other drug abuse among peoplewith additional disabilities are oftenoverlooked or ignored. The healthcare provider community may failto recognize the signs of alcoholabuse or may look the other way.

MARY C. DUFOUR, M.D., M.P.H., ischief of the Epidemiology Branchof the Division of Biometry andEpidemiology, NIAAA. DARRYLBERTOLUCCI. M.A., is a mathemati-cal statistician with the Division ofBiometry and Epidemiology,NIAAA. CAROL COWELL. B.A., is astatistician with the Office of Fi-nancing and Coverage Policy, Na-tional Institute on Drug Abuse.FREDERICK S. STINSON, PH D., is a

senior analyst with the AlcoholEpidemiologic Data System(AEDS). JOHN NOBLE, B.A., is theDeputy Director, Divisio.i of Biom-etry and Epidemiology, NIAAA.

For additional information,please contact Dr. Stinson at Alco-hol Epidemiologic Data System,CSR, Incorporated, Suite 600, 1400Eye Street, NW, Washington, DC200J5. Telephone: (202) 842-7600.

Is.

There have been few nationaldata collection efforts regarding thenumber of alcohol-related hospital-izations among it dividuals withadditional disabilities. This bulletinexamines the alcohol-related mor-bidity for disabled Medicare enroll-ees for 1985. TWo national data setswere used in this study: one to de-scribe the alcohol-related hospital-ization experience of the U.S.general population in 1985 and theother to describe, for the same year,the hospitalization experience ofthose individuals who are disabledMedicare enrollees.

THE NATIONAL HOSPITAL

DISCHARGE SURVEY

The first data set is the NationalHospital Discharge Survey (NHDS)of the National Center for HealthStatistics (NCHS). Public useNHDS tapes for 1985 were used inthis study. The NHDS randomlysamples discharges from non-Federal hospitals with six or morebeds and an average length of stayunder 30 days (i.e., short-stay hos-pitals). The hospital sample is strat-ified by size and geographic regionof the United States, and appropri-ate weights are provided to calcu-late national estimates (NCHS1970).

Each record in the NHDS de-scribes a hospital episode for anindividual patient. The followingitems are provided for each hospi-talization (or discharge):

age, sex, race, marital status, andlength of stay for the patientsize and regional location of thehospitalas many as seven diagnostic codesand four procedure codes describ-ing the patient's diagnosis ant!treatment.

The NHDS allows space for codingfrom one to seven diagnostic catego-ries on a discharge record. "First-listed" refers to the diagnosticcategory mentioned first on therecord. This code is presumed to bethe principal diagnosisthe mainreason for the hospital admission."All-listed" refers to diagnostic cate-gories mentioned any place on thedischarge record, with or withoutany all-listed set of diagnoses. It isimportant to keep in mind that theNHDS tabulates discharges ratherthan patients. Fo; example, if 10discharges are recorded for a givenrrignosis, this record may reflecthospitalizations for 10 separate pa-tients or one individual hospitalizedfor the same problem 10 times.

ALCOHOL HEALTH & RESEARCH WORLD

MEDICARE PROVIDER ANALYSIS AND

REVIEW FILE

The Health Care Financing Admin-istration's (HCFA) Medicare Pro-vider Analysis and Review(MEDPAR) file is the source of theMedicare hospital inpatient dataemployed in this study. Informationavailable in this file includes: age,sex, first-listed diagnosis and up tofour additional diagnoses, length ofstay, eligibility (aged or disabled),and reimbursement data. The datafile used in this study is the 1985MEDPAR file for the disabled.Disaoled individuals who are listedin this file are those who meet thecriteria for the Social Security Dis-ability Insurance Program (Lubitzand Pine 1986). Although this dataset in no way captures the entirepopulation of disabled personsunder 65 in the United States, itincludes those so seriously disabledthat they cannot work. One partic-ular strength of the Medicare dataset is that it is population based(rather than a sample). Also, al-though it resembles the NHDS intabulating discharges rather thanpatients, another strength is thatthe Medicare data provide patientidentifiers that can be used to ac-count for multiple hospital episodesinvolving the same patient. In 1985,there were nearly 3 million disabledMedicare enrollees (HCFA 1988).

In general, NIAAA publicationson the NHDS provide data on fourage groups: 14-24 years, 25-44years, 45-64 years, and 65 yearsand older. However, since over 70percent of disabled Medicare enroll-ees are between 45 and 64 years ofage (HCFA 1988), NHDS dischargerates for patients ages 45-64 wereused in this study for comparisonwith the disabled MEDPAR hospi-tal discharge records.

For the purposes of this study,the discharge records informationwas translated into categories based

DIAGNOSTIC CATEGORIES USED IN THEMORBIDT/Y STUDY

For this studt &tailed codeshem .11sefirtersterforitaassf.

fleatiOn'OP*41*-9* Revision,ablkidrifindaintinet nese re-cot d oste Orlin followingnut* i ed Categories:'

Aid dinikaloolgOdiltinwel delirium120i*aloobritainneititayndoome1291.11:

other alcoholic dementia 1291.21alcohol Withdrawal hallucinosis(291.31-idiosyncratic slcolsol intoxica-tion 1291.41alcoadic_ jealousy [291.5]other specified alcoholic psy-diosii 091.8]unspecified alcoholic ,ychosis(291-91

Alcohol Dependence Syndromeacute alcoholic intoxication[303.0]other and unspecified alcoholdependence [303.9]alcoholic polyneuropathy[357.5]alcoholic cardiomyopathy[425.5]

alcoholic gastritis [535.3]pellagra [265.2]

anomie liver Disease andUnhook

Alcoholic Cirrhosis of the liveralcOholic fatty liver [571.0]acme alcoholic hepatitis [571.1]alcoholic cirrhosis of liver[511.21aicohobc liver damage, unspeci-fied (571.31

ammo*, odits SpedtlelWhboit Menden of Alcohol

chronic hepatitis [571.4]billary cirrhosis [571.6]other chronic non-alcoholic liverdisease [571.8]portal hypertension [572.31

Cirrbods, Unspecified WithoutMeador of Alcohol

cirrhosis of liver with mentionof alcohol [571.5]unspecified chronic liver diseasewithout mention of alcohol[571.9]

Nondependent Abuse of Alcoholalcohol abuse [305.0]

on the International Classificationof Diseases' lists of alcohol-relateddisorders (CPHA 1978). The ac-companying sidebar provides addi-tional details on methods.

RESULTN: A DOUBLING OF RISK FOR

ALCOHOL-RELATED DIAGNOSES AMONG

1 HE DISABLED

According to the NHDS, in 1985there were approximate:y 35.1 mil-

lion discharges (excluding newborninfants) from short-stay hospitals.In nearly 600,000 (1.7 percent) ofthese, the principal or first-listeddiagnosis was alcohol related. Inorder to take population differencesinto account, this type of informa-tion is more meaningfully expressedas rates. In 1985, the discharge ratefor any diagnosis was 1,479 per10,000 population age 14 and older

Vox.. 13, Na 2, 19119 159

t;

Epidemiologic Bulletin

(NIAAA, in press). Table 1 listsdischarge rates for several common,well-known conditions in order toprovide a frame of reference for thediscussion that follows.

Figure 1 illustrates that thealcohol-related discharge rates weredramatically higher for the disabledthan for the general population asrepresented by the NHDS. For mostalcohol-related diagnoses, dischargerates for the physically impairedsample are more than double thosein the NHDS. The pattern ofalcohol-related diagnoses amongthe disabled mirrors closely that ofthe population as a whole. The va't

. .

Table 1 Diseiserges from UAL likort-litay itomitals, DM

Firsitisisd Diagnosis Rates/10,000 Population

Any diagnosis 1478.9

Alcohol-Mated ' 31.2

FOr11811391wIth deliveries fiCO-V271 2 314.8

Fractures, aN WM(800-8293 47.6

Haan Mack (souls myucarcirdintarclion-4101 31.8

Gallstones Ichoislithimis.5741 20.0

Lung cancer (malignant neoplasm of trachea,bronchus, and lung-182, 197.0, 197.3) 13.3

Ras Ply 10,000 paps on ago 14 and oldst2 RIM per 10.000 tycoon.sconce tido* Gnat for Himith Sc,,tatiari 1988

Quick FactsFROM NIAAA

For persons interested in up-to-date information onthe scope and consequences of alcohol use Ind abuse,the National Institute on Alcohol Abuse andAlcoholism provides an electronic bulletin boardsystem called Quick Facts. The system currentlyprovides access to over 60 tables of data on alcoholconsumption, drinking patterns, alcohol-relatedmorbidity and mortality, other consequences ofalcohol abuse, and utilization and costs of alcoholtreatment. The information available through Qua kFac ts is updated periodically and the scope ofcoverage is constantly growing

Quick Fac is offers the following features

No fee for subscription or access,Online availability 21 hours each day (24 hours onweekends),

160

AL c e by use of a modem with and computerterminal Cr microcomputer, andLuse cif u.se, with online table of contents and index,help screens, an i written user's manual available

Use QI41( k Fac is immediately by establishing the cor-rect modem settings (8 data bits, I stop hit, no parity.fail duplex or no local echo, and 24(X) or 12(X) o: 300baud transmission speed) and by calling 202 -289-4112

Quick Facts is a service of the Alcohol Epi-demiologic Data System, a contract operated forNIAAA's Division of Biometry and Epidemiology byCSR, Incorporate.. For more information about Qui( kFa( is or for assistance when using the system, contactFred Stinson at 202-842-7600

t)Al COHOI HEA I TH & RESEARCH WORLD

Clearly, a significantamount ofalcohol-relatedmorbidity exists in thedisabled community.

majority of first-listed alcohol-related diagnoses for both groupsfell into the category of alcoholdependence syndrome followed byall cirrhosis.

The results of this study are strik-ing. Clearly, a significant amountof alcohol-related morbidity existsin the disabled community. Pre-vious research (Stinson and Wil-liams 1986) has shown that first-listed diagnoses account for a littlemore than half of all the alcohol-

related morbidity listed in theNHDS. Therefore, when only first-listed diagnoses are examined,alcohol-related morbidity in short-stay hospitals is underestimatedsubstantially. This underestimationundoubtedly holds true for theMEDPAR data as well. Thus, thetrue magnitude of alcohol-relatedmorbidity among the disabled isquite likely to be even more pro -no "nced than reported in thisstudy. II

REFERENCES

Commission on Professional and HospitalActivities (CPHA). The International Classi-fication of Diseases, 9th Revision, ClinicalModification, Vol. 1, Diseases Tabular ListAnn Arbor, MI. CPHA, 1978

Health Care Financing Administration.Annual MEDICARE Program Statistics:Medicare Enrollment, 1985. HCFA Pub. No.03266. Washington, DC: Supt. of Docs.,

U.S. Govt Print Off , 1988.

LUBITZ, 3 , AND PINE, P Health care use byMedicare's disabled enrollees Health CareFinancing Review 7(4):19-31, 1986.

National Center for Health Statistics. Devel-opment of the design of the NCHS HospitalDischarge Survey. vital and Health Statis-tics. Series 2, No. 39, PHS Pub. No. 1000Washington, DC: Supt. of Docs., U.S. Govt.Print. Off., 1970.

National Center for Health Statistics. Sum-mary. National Hospital Discharge Survey,1985. NCHS advance data No. 127, Septem-ber 25, 1986

National Institute on Alcohol Abuse andAlcoholism. U S. Alcohol EpidemiologicData Reference Manual, Vol. 4: Alcohol-Related Morbidity Among Short-Stay Com-muhity Hospital Discharges, United States,1979- 1985..n press.

STINSON, ES , AND WILLIAMS, G.D. Surveil-lance Report #4: Alcohol-Related MorbidityAmong Short-Stay Community HospitalDischarges, United States, 1979-1984. Wash-ington, DC. Alcohol Epidemiologic DataSystem, 1986.

My alcohol-related diagnosis

59.1

Alcohol dependence syndrome

, AN chronic liver disease and

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

Medicare/DisabledNHDS/Ages 45-64

VOL. 13, No. 2, 1919te;

161

READERS'EXCHANGE

HEARING-IMPALRED

ALCOHOLICSANUNDERSERVFBCOMMUNITY

In the United States, more i'lan 20million people suffer from in-

paired hearing (Wentzel 1936; U.S.Bureau of the Census 1987). Howmany of 0 em have the dual prob-Ian of alcoholism and hearing loss?Exact data are not available; how-

a conservative estima,z, basedon the National Council on Alco-holism's assumptions about theprevalence of alcoholism in the gen-eral population, suggests that atleast 600,000 men and women ape-'ence this doable burden.

Given the state of the art of alco-holism treatment services, how manyhearing-impaired persons can expectto find help for their alcohol-relatedproblems? Resources available tohearing people, from AlcoholicsAnonymous (AA) to professionaltreatment facilities, are fraught withbarriers for those who cannot hear.The resources depend on communi-cation among individuals, communi-cation between individuals and agroup, or the "simple' act of listen-ing to a film or talking on the tele-phone.

Four years ago, my brother at-tendx1 AA meetings many times aweek for four months. . . . Me]didn't drink for four months buthe didn't hear a word that wassaid in meetings. My brother wentbazk to drinking and is still drink-ing. . . .

[U]sing standard treatmentmethods [of a 28-day inpatienttreatment program], I had tostruggle with the grou 4:ssioris inorder to follow my fellow pa-tients, and part or the strategy

162

the constant interaction withpeople from morning tobedtimeleft me exhausted ar_ifrequently frustrated. . . .

What is the explanation for this lackof awareness and the relative absenceof measures to meet the needs ofhearing-impaired and deaf alco-holics? And how can these problemsbe corrected?

SOCIETAL %SPONSE TO HEARING

IMPAIRMENT

Hearing impairmentthe most com-mon sensory lunitition in the UnitedStates (U.S. Bureau of the Census1987)is a broad teem embracingdegrees c,f loss from mildly "hard ofhearing" to profoundly deaf. The lossis measured in decibels (dB) that de-scribe the ability of an individual tohear sound, as depicted in Table 1.The "profound loss" category in-cludes persons who are deaf as well assome in whom residual hearing isretained. Deaf persons are those forwhom the sense of hearing is non-functional for the ordinary purposesof life. Deafn,ss refers to both thecongenitally deaf and the adventi-tiously deafthose in whom the senseof hearing has become nonfunctionalthrough illness or accident.

A variety of organic and erviron-mental factors may be involved inhearing loss. As a consequence, hear-ing impairment includes various com-binations of middle-ear dysfunction,inner-ear dysfunction, bone dysfunc-tion, and nerve damage. These condi-tions are expressed in the quantitativeand qualitative differences in hearingloss and in the responses and equip- 2

GIADys A. Kt 4RNS IS executive directorof the Union County Counril onAlcoholism, 300 North .4venue E.,Westfield, New Jersey 07090.

ALCOHOL IL, 11.4 & RESEARCH WORLD

IIMMEMIMIL

Jr

z

.

Readers' Exchange

ment required to address the loss or,when possible, to enhance and am-plify sound. When the condition orthe circumstances do nc permit en-hancemeat or amplificatior of sound,a hearing-impaired individual mayattempt to rely on sign language,interpretation, or lipreading. Withoutthese aids, a hearing-impaired personis consigned either to loneliness or toa ceaseless struggle to function in aworld where verbal conanumcation isthe common method of socialbonding.

A general assumption in the hear-ing and speaking world is that allhearing impairments other than ,ro-found deafness fit under the genericumbrella of "hard of hearing." Allhard of hearing people often are per-ceived as similarly afflicted andsimilarly able to cope with the envi-ronment. In effect, hearing-impairedindividuals are viewed r no differentfrom those who hear.

. I wear two hearing aids (onlysince I was 20 or so; I wouldn't doit as a kid for fear of en'b-rass-ment) but so many do not under-stand [that] they are just aids. Theydon't make us hear like other peo-ple. People expect that those of ususing hearing aids should be able tohear like they do! It is so very frus-trating and more so trying to ex-plain , . . that I only hear betterwith them than I do without themand [that] I still miss a lot!

164

This inaccurate perception about thenature of hearing :z.pairrhent mayresult in the failure to respond to theneeds of hearing-impaired persol-s,compared with the responses offeredto those whose disabilities are morereadily observed and understood(Buss 1985).

On an individual level, insensitivityto the special needs of hearing-impaired persons may translat° into anegative self-perception.

. . . It really hurts when a friendge,s angry at having to repeatsomething for the 100th time androlls his head or his eyes upward; Ihate setting them get as frustratedas I am. . . .

Such experiences inadvertently mayimpart a sense of social stigma.Hearing-impaired persons may with-craw from the hearing world or denythe exist: we of a hearing loss. Thesebehaviors at the last lay the ground-work for isolation, and it has beensuggested that a high level of frustra-tion may increase he incidence ofalcohol abuse among the hearing-

impaire.. population (Harris 1982).

Tin Roo.: OF SFJOICE NOVIDFAS

Isolation and denial of an impairmentare patterns familiar to the alcoholismtreatment community. lleatmentprofessionals recognize that thesetraits decrease the likelihood of identi-fying problems, minimize a client's

acceptance of special needs, and re-duce the probability of a positivetreatment outcome. Alcoholism treat-ment service providers forge a criticallink in the service delivery and recov-ery chain for the hearing-impairedalcoholic (Wentzel 1986).

Unfortunately, this role is notadoptei effectively by many treatmentservice providers. Alcoholism serviceproviders are not immune to ina( cu-rate perceptions concerning hearingloss. The varieties and degrees ofhearing impairment and the effect ofa given loss upon an individual re-main unexplored areas for most pro-viders. When alcoholism treatmentproviders succeed in penetrating thebarrier of self-protection raised by thehearing-impaired alcoholic, neitherthe alcoholism treatment service sys-tem nor the network of service deliv-ery for the hearing impaired offersmany resources designed to help inter-vention with the client. As a result, ahearing-impaired alcoholism clientmay fall through the gaps in a servicedelivery system (New Jersey TaskForce 1986). According to one recov-ering author:

. . . the biggest stumbling blockto recc -ry hinged on somethingeveryone missed: the real emotionalacceptance of my hearing loss.Outwardly I handled my hearingloss in . . . a manner that did notgive evidence to the profound deaf-ness that I have. . . . I successfullyhid behind this "mask" for 38years. I now realize that my intensefight '- be "normal" and my suc-cess in so doing was the real "de-nial" in my life. The professionalsmissed in not steering me towardsthe acceptance of my hearing logsand the limitations it places on me.

As for life after treatmentprofes-sionals must recognize 1 v hearingloss isolates us from people, and po-ple are the key to one's success inAlcoholics Anonywous (Jestrrger1988).

t*-1 ALCOHOL HEALTH & RESEARCH WORLD

In 1984, the governing body ofUnion County, New Jersey, contractedfor a survey on the appropriateness,availability, and accessibility of alco-holism and related treatment servicesfor county residents with mental andphysical disabilities. Through the endof data collection in June 1986, atotal of 14 alcoholism treatment pro-grams and 15 agencies serving theneeds of hearing-impaired people werereviewed under the administration ofthe author. Virtually all of the generalobservations on the barriers co treat-ment were confirmed by the surveyresults. No treatment program ordisability service agency in this rela-tiwly weaithy jurisdiction or morethan a half mil:ion population wasprepared to offer the resources neces-sary for treatment of hearing-impairedalcoholics.

Specialists who serve hearing-impaired people also face lirge gapsin information and resource; relatedto the deaf alcoholic. The Inyth thathearing loss "explains" alcohol depen-dence is pervasive within the commu-nity of service providers for thehearing impaired, and such providersmay fail to recognize alcohol-relatedproblems among their clients. Thesame denial that a hearing personuses to mask alcoholism can be read-ily applied by a hearing-impairedperson to mask a dual problem, espe-cially if alcoholism and hearing lossar rceived as deviant social charac-tenstics. In those rare cases in which aspecialist on hearing loss identifiesand attempts to meet the needs engen-dered by a dual problem, the specialistoften may experience a sense of help-lessness. Resources are difficult to:btain for someone who cannot hear

group situation, who cannot usethe telephone, or who cannot hear atall.

CORRECONG THE PROBLEM

Three types of activities must be un-dertaken to correct the absence ofservices for the hearing-impaired alco-

VOL. No. 2, 1939

holic. First, hearing-impaired peoplemust continue t3 work as activists,exercising leadership in raising andmaintaining social awareness of theissue of alcohol-related problemsamong their population. Second,society must respond to the dual dis-ability cf hearing impairment andalcoholism with the same caring con-cern directed toward other impairedpopulations. Finally, it is essential thatservice providers responsible for inter-vention among alcoholics and inter-vention among the hearing-impairedpopulation move vigorously towardmutual education to spur the develop-ment of necessary services andresources.

Among human service providersand an increasing number of clini-cians, 't is a truism that recovery ismost effective when the client be-comes an active and knowledgeablepartner in the treatment plan. Activeparticipation recently was demon-strated when deaf students at Gal-laudet University in Washington, DC,successfully protested the appointmentof a hearing president and obtainedthe appointment of a qualified deafpresident for the national universityfor the deaf. Society's response to theGallaudet students' action was imme-diate. Television, radio, and newsprintprovided thoughtful, comprehensivecoverage during the week-long debatebetween students and 0- universityboard of trustees. As a result, manypeople became sensitized to the sec-ond class status that unwittingly maybe ascribed to hearing-impairedpeople.

A less dramatic approach to self-help leadership among hearing-impaired persons is provided by SelfHelp for Hard of Hearing People,

(SHHH), based i i Bethesda,Maryland. According to founder andexecutive director Howard E. Stone,"SHHH was founded based on theconviction that little progress can bemade until both those who can hearwell and those who cannot better

understand the nature, causes, com-plications, and possible remedies ofhearing loss" (Stone 1987). Member-ship in such self-help groups mayassist hearing-impaired persons todevelop the confidence to insist upona response to their needs.

. . . TI; biggest problem I havenow is that although I have thiswonderful auditory trainer, peopledon't like to use it and it is veryhumiliating to ask/explain to themembers of the AA group aboutit. . . . A few times I got ruderemarks about the mike and blewup and told them I don't like iteither . . . but I want to staysober too. . . . They don't have touse it but just pass it to the nextone who is willing to share withme.

Sensitivity to such problems isneeded by communities that designand fund programs to serve peoplewith alcohol-related problems. Severalyears ago, for example, the lack ofcommunity-based treatment resourceswas cited as a contributing factor tothe suicide of a young hearing-impaired alcoholic. The attentionfocused by the incident enabled PaulRothfeld, executive director of CapeCod Alcoholism Intervention andRehabilit.;:ion Unit, Inc., to found theStephen Miller House in Pocasset,Massachusetts, as a memorial to thirtragedy. Now funded by the State o'.

assachusetts, the Stephen Millerprogram focuses jointly on the prob-lems of hearing impairment and alco-holism while offering information andcounseling to the families of its clientsand to the deaf community through-out the region ( Rothfeld 1980).

The process of sensitizing com-munities to the ..ids of hearing-impaired alcoholics does not requirethe spark of tragedy. AlcoholismIntervention for the Disabled (AID) isa further example of social action inthe design of a helping mechanism.

165

Readers' Exchange

Founded by Alex Boros of Kent StateUniversity, AID now publishes aquarterly newsletter for national distri-bution. lbpics covered in the newslet-ter include practical, state-of-the-artinformation for consumers and pro-viders of alcoholism and other addic-tion services.

Although individuals and groupsmay work for change, the agenciesand institutions responsible for serv-ing people struggling with alcoholismand with hearing loss must acknowl-edge institutional needs for special-ized, reciprocal education. Sucheducation may include sensitivitytraining for both types of serviceproviders. At a minimum, educationmust address the myths and biasesthat affect service delivery to hearing-impaired alcoholics.

In addition to education, alcohol-ism treatment services must developawareness of the need to match spe-cial equipment and services to specifictypes of hearing loss. All hard-of-hearing or deaf people cannot beexpected to benefit from the listeningpotential supplied by a given piece ofequipment or communication tech-nique. Louder, for example, is notnecessarily better. Hearing aids helpsome individuals but not all. Personalhearing aids, even when effective forone-to-one communication, mayrequire reinforcement by auxiliaryequipment for us' in groups, includ-ing AA meetings (Cutler 1985).

Reatment facility operations alsomay be affected by the requirementsfor effectively responding to hearing-impaired alcoholics. For example,background noie that merely distractsa client with normal hearing maytotally distort a message directed to aclient with assisted hearing. Visualcues that are essential to many lip-readers require good lighting. Theavailability of alerting devices is im-portant for critical functioning ordangerous situations, particularly ininpatient treatment: Think of traveling

166

to an unfamiliar location without theuse of your ears! Service providersshould view meeting such require-ments as a prime determinant ofsuccessful program outcome forhearing-impaired alcoholics.

Above all, treatment service pro-viders need untinstanding. Peoplesuffering froTri hearing loss are shutout from spoken language, our majormeans of communication. Languageis a critical component of psychoso-cial development because of its role asa bearer of culture, a transmitter ofinformation, and the primary meansof presenting a. self -image to theworld. Spoken language conveysmoods, needs, and many other sharedexperiences among people. Whenlanguage acquisition if prevent' d byearly, profound hearing loss or whencommunication is diminished by lateronset of hearing impairment, hearing-impaired people are distanced and feelclis...ace from their fellows (Harris1!82). Helen Keller's emphasis on herhearing loss over her blindness ex-pressed the sense of distance when shesaid that blindness separated her fromthings but deafness separated herfrom people (Keller 1954). Some ofthis separation must be closedthrough understanding if alcoholismservices are to provide genuine recov-ery for hearing-impaired people. XI

Quoted passages in this article are excerpted

from letters received try the author in response tothe publication of a recent article (Kim /987).

REF1ENCES_

Buss, A. Alcohol use by persons with disabilities/irDBqletat7(1) 1-3, 1985.

a-r ER, W B. large Room Lsterung Systems forFlare of Hearing Ito* Bethesda, MD Self114 for Hard of Hearing People, Inc., 1985

RIS, R.I. Communication and mental healthThe Deqf American 34(4) 8-12, 1982.

JESFURGER, C A hard of hearing alcoholic finds

recovery. Shhh Journal 9(2) 23, 1988

KEARNS, G. AleChOLLSM and hearing loss' A

silent conspiracy? Shhh Journal 8(6)12-13, 1987

KELLER, H. The Cory of My Life. New Y:Alc.Doubleday, 1:54.

New Jersey 'Disk Force on Alcoholism and theHearing Impaired "Report to the New JerseyDivision of Alcoholism." Unpublished report,June 1986.

ROTHFELD, P Alcoholism treatment for the deaf:Specialized services for special people. CAFr.Arlington, VA: H/P Publishing Co., 1980.

Srorge, H E. Invisible handicap. Baltimore Sun,Dec. 29, 1987.

U.S. Bureau of the Census. Stattsncal Abstnacl ofthe Uruted States 19. 108th ed. Washington,DC: U.S. Bureau of the Cerkas, 1987. 'able174, p. 108.

WENTZEL, C An outline for working with thehearing unpaired in an inpatient substance abusetreatment program. AID 'ern 8(1)'' -6, 1986.

IML

ALCOHOLISM AND

BULLOUS CHANGES OF

THE LUNGS

Some pulmonary patients arediagnosed with bullouschanges of the lungs. Thisdiagnosis refers to the pres-

ence of blisters, known as localizedpneumatoceles or bullous formations.Textbooks ci cribe the origin of thebullous ch Angts as obstruction of thebronchioles, the narrowest portions ofthe bronchial tube. According to thisview, air can be trapped within ob-structed bronchioles, resu!ting in theformation of Msters within the lung.The following alternative hypothesisto explain bullous changes of thelungs is based on many years of ob-servation of chest x-rays of alcoholicpatients, including over 100 casesin which a diagnosis of billionschanges was associated with alcoholdependence.

SIDNEY L. CRAMER. M.D., is a radiolo-gist consultant to the Veterans Homeand Hospital, Rocky Hill, Connecti-cut. Conespondence to Dr. Cramershould be addressed to his privatepractice at 21 Woodland Street,Hartford, Connecticut 06105.

ALCOHOL Ifd-ALTP & RESEARCH WORLD

X-ray photograph illustrating bullous changes

It is hypothesized that many peoplehave a physiological susceptibility topulmonary effects of alcohol con-sumption. This population developssubclinical destruction of cells in thelung tissue, beginning in the upperlobes, in response to repeated con-sumption of large quantities of alco-hol. Hyp 'hetically, this destructioncontinues W .1 Cie patient stopsdrinking alcoholic beverages. The endresult of the cell destruction is upperlobes with varying degrees of bullousformations, ranging from a smalllesion measuring several centimeters in

VoL. 13, No 2, PO

diameter (as shown in Figure 1) tolarge areas characterized by fibrosisthe formation of abnormal fibroustissue and the absence of normallung markings within the air sacs.Such permanent, irreversible change,,can be observed in the lung tissue ofalcoholic patients. These changes arenot seen in chest vcaminations ofsn_Jkers or nonsn lkers without thecomplication of pre ant or formeralcohol abuse.

My observations suggest that theeffects of destruction of the lungtissue may take one of two possible

courses. Among some patients, noother significant changes in the lungoccur unless complicated by infectionor the presence of air or gas in thepleural cavit j. These patients oftenpresent neither symptoms nor altera-tion in pulmonary functionthepresence of bullous changes usually isdiscovered from routine chest x-raystaken for reasons other than breathingcomplaints. These patients can bedescribed as Group I.

A second group of patients withbullous formations also present clini-cal symptoms of emphysema, alongwith the characteristic x-ray evidenceof this well-known lung disease. Ihave found these Group II patients inlarge numbers in such institutions asVeterans Administration hospitalswhere care is provided for chroniclung disease. These Group II patientsoften are pulmonary "cripples"receiving treatment with alpha 1anti -trop; i subs itution.

The Group 1 patients frequentlydeny a histor of alcohol consump-tion, but confirmation often is ob-tained from such other sources asrelatives and friends. Through dili-gence and persistence in eliciting thehistory of alcohol use, over 90 percentof 100 observed cases of bullous for-mations confirmed the hypothesis.

Although these observations areintriguing and potentially significant,I believe that it will be very difficult toconfirm them empirically. Most indi-viduals who drink at problematiclevels also smoke tobacco products;bullous changes resulting from smok-ing pose a potential barrier to analysisof the relationship between alcoholabuse and lung disorders. Further,unless alcohol-induced bullouschanges can be separated omchanges affected by tobacco use,specific mechanisms explaining therelationship between alcohol and theselung disorders will be difficult toestablish. IM

167

OccupationalArena

Treating Patients withAlcohol-Related TraumaA Report from the ARUSSymposium

A 28-year-old man comes in withbasically normal vital signs,semiconscious and vomiting,some cuts about his scalp andaround his ears. He is ratherobnoxious, not a very pleasantcharacter to be around, andsmelling like a bottle of whiskey.

One of the residents says, "Oh.he is just drunk." And, indeed,he is drunk. But he also has amajor intercranial clot. . . .

There has been an unfortunatetendency to get patients in theemergency room who ale drunk. . . and to label them. . . .

If you are medically oriented,you may have heard them called"gomers."

What does gomer mean?It means "get out of my emer-

gency room."Soderstrcm, M.D.'

Each year more than 140,000Americans dic from trauma, and 1in 3 incurs an injury that requiresmedical attention or produces tem-porary disabili.:y (Committee onTrauma Research 1985). Trauma is

' The source of quoted material in thisarticle is the transcript of the June 1988Alcohol Research Utilization System sympo-sium "Post-Injury Theatment of Patientswith Alcohol- Rela!ed Thauma." A synopsisof the transcript Ls available fm, the Na-tional Caartnghouse for Alcohol and DrugInformation, P.O. Box 2345, Rockville,Maryland 20857. Also avallab.'2 from theclearinghouse is "4 /who? and Thauma," theJanuary 1989 Issue of Alcohol Alert, abulletin for clinicians and allied healthprofessionals.

168

ranked as the country's fourth lead-ing cause of death and the leadingcause of physician contacts Rock-ett and Putnam 1986).

Victims of serious trauma findmedical help in over 5,000 hospitalemergency departments and 300trauma centers throughout theUnited States. It has been estimatedthat 20 to 37 percent o; adinissionsto these acute care facilities involveexcessive alcohol use (Roizen 1985).According to Julian Waller, M.D.,of the University of Vermont's De-partment of Medicine, contactsbetween acute care physicians andvictims of alcohol-related trauma"offer a unique window of oppor-tunity . . . if the physician helpsthe patient confront the [alcohol]probler' when the patient is nolonger under the influence . . .

but is still hurting from injuriescaused by the alcohol abuse." Con-versely, failure to identify and inter-vene with an underlying alcoholdisorder could result in medicalmismanagement of the injury, sub-sequent injuries ,esulting from un-treated alcohol abuse, or both.

Problems that ph) -.tans encoun-ter when addressing a j. t'sinjury and an underlying a ohoAdisorder were examined by p.pants in NIAAA's Alcohol Re!. ;archUtilization System (ARUS) sympo-sium "Post-Injury Treatment ofPatients with Alcohol-RelatedTrauma," held in June 1988 inWashington, DC.' Clinicians andresearchers who attended the A RUSworkshop reviewed research on

The ARUS series, initiated in /980, is aforum for the assessment of knowledge anda limned number of high priority researchfindings in a specific area of alcohol st idv

alcohol-related injuries and identi-fied promising avenues for futurestudy. Participants also suggestedways to exploit what DouglasRund, M.D., chief of emergencymedicine at 01 State UniversityHospital, termed "that brief mo-ment of care in the trauma event. . . when the alcoholic traumavictim will accept treatment foralcoholism" (personal communica-tion, Fulton Caldwell, Ph.D.,NIAAA, January 1989).

Chaired by Albert Lowenfels,M.D., professor of surgery at NewYork Medical College at Valhalla,the 1-day workshop featured ple-nary sessions on diagnosis of alco-hol dependence in injured patients;early management of patients withalcohol-related injuries; alcohol-induced physiological alterationstrauma victims; and interventionand followup for alcoholic patients.Obstacles that emergency physiciansencounter at each stage of patientcare were highlighted.

RECOGNIZING ALCO:101, DEPENDENCE

The World Health Organization'sInternational Clasjfication of Dis-eases, 9th Revision (ICD-9) de-scribes the outward manifestationsof nondependent alcohol abuse asfrequent, excessive drinking suffi-cient to adversely affect one'shealth or social functioning (WHO1977). The American PsychiatricAssociation's Diagnostic and Statis-tical Manual of Mental Disorders,Third Edition, Revised (DSM-III-R) describes alcohol abuse as aninability to stop drinking until poorhealth or depleted financial re-sources prevents further drinking(APA 1987).

At least intil its late stages,

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 identifiedprimarily by these same manifesta-tions. DSM-III-R notes "marked. . . impairment in social andoccupational functioning" (p. 172)in alcohol dependent persons.ICD-9 describes alcohol depend-ence syndrome as "characterized bybehavioral and other responses" (p.198). Because few of these re-sponses are observable in clinicalsettings, the diagnosis of alcoholdependence often relies largely onpatient self-report of medical, so-cial, or financial problems related

to alcohol use and on a diagnosti-cian's interpretation of that pa-tient's self-report.

Instruments that are used forscreening alcoholic patients alsorely heavily on patient self-reports,an assessment mechanism that hasbeen challenged (Watson et al.1984; Fuller et al. 1988). In addi-tion, according o KathrynMagruder-Habib, of the VeteransAdministration Medical Center andDuke University, most -...reeninginstruments a-c long, cumbersome,

and poorly suited to administrationin an acute care setting.

Trauma physicians suspect alco-hol dependence largely on the basisof what they see, which, in an acutecare setting, is less often the adverseeffect of alcohol on social or occu-patiGnal functioning than the moreobvious evidence of intoxication.However, signs of recent alcoholuse ck, not justify a diagnosis ofdependence; in fact, alcoholics withwell-developed tolerance often showno outward manifestations of re-cent alcohol use.

Voi- 13, Na 2, 1969 r169

DEPARTMENTS

Correct identification of alcoholdependence is further complicatedbecause visible signs of intoxicationmay mimic signs of other condi-tions. For sample, patients whoare unconscious or display alteredcorsciousntcs as a result of headinjury sometimes are misdiagnosedas under the influence of alcohol.Similarly, patients with altered con-sciousness brought on by alcoholabuse may be misdiagnosed as vic-tims of head injury. The "gomer"referred to by Soderstrom, of theMaryland Institute for EmergencyMedical Service Systems(MIEMSS), is one example ofmisdiagnosis.

"Unless you actively seek out thedisease," urged Waller, "jou willmiss all except those individualswith the most flagrant, late-stagedisease patterns. . . . and the onlyway to know how much a personhas been drinking is to do a quanti-(al ive test for the drug."

MEASURING ALCOHOL Usl,

The quantitative test most fre-quently employed is that for bloodalcohol concentration (BAC), some-times measured for legal reasons atthe scene if a highway accident,but routinely measured in km),about 50 percent of trauma centers,according to Soderstrorn.

As Wailer poi"ted out, the legellydefined measui of intoxicationactually captures only 18 percent ofintoxicated drivers. For this reason,some States are taking action toredefine the current measure of .10milligrams of alcohol per deciliter ofblood as evidence of intoxication.

Measured in hospital emergencydepartments and trauma centers,the BAC has significant limitationsas an indicator of possible alcoholdependence. According to Waller, a

170

Given the limitationsof current testingoptions, how doemergency carephy,icians diagnosealcohol dependence?

relatively low BAC may preventidentification of elderly alcoholics,whose typical alcohol consumptionis only four drinks a day. On theother hand, high BACs are c im-mon among teenaged alcoholabusers, who usually have not con-sumed sufficient quantities of alco-hol over a long enough time to bealcohol dependent.

However, the BAC does provide aphysician with information aboutthe amount of alcohol in a patient'ssystem at the tame of admissioninformation that can prove essentialin determining a course of treat-ment recommen-dation by the U.S. College ofSurgeons, symposium moderatorLowenfels called on conferenceattendees to recommend routine useof the BAC in all trauma centersand emergency departments.

Laboratory tests that may alerttrauma physicians to excessive alco-hol use and to possible dependencein their patients include -levatedliver function tests without obviousexplanation, elevated triglycerideswith relatively low cholesterol, andelevated blood glucose without afamily history of diabetes or, con-versely, low blood sugar or reactivehypoglycemia. None of these mea-sures is routinely applied to alltrauma victims, and none indepen-

dently is indicative of more than apossible alcohol-related problem.

Given the limitations of cui renttesting options, how do emergencycare physicians diagnose alcoholdependence? According to Wolterand to discussant Peter Fielding,M.D., of St. Mary's Hospital andYale University, the question is notdiagnosis but "screening andyield." "The jot a physicianwho is not a specialist in this area isto Know when and how to do ap-propriate screening and to get thepatient into the hands of the neces-sary alcohol specialist," said Waller.

Waller suggested a BAC of .15without cliri =al evidence of intoxi-cation as indicative of high patientrisk of alcohol dependence. He alsorecommended several short screen-.ng instruments,' of which the mostrecently developed consists of onlytwo questions. Cyr and Wartman(1988) reported that a positive an-swer to the question "Have youever had a drinking problem?" waspredictive for 70 percent of personswith alcohol-related problems. Ac-curacy was raised to over 90 percentfor persons who, when asked,"When was your last drink?" an-swered that they had consumedalcohol within the past 24 hours.As W-iller noted, a positive BACobviates the need to ask the secondquestion

A!tiiough Fielding and Wallerconcluded that patients who testpositive in alcohol scieeningsshould be referred to alcohclcialists, the reality is that acute carephysicians gife priority to treatingthe immediate trauma rat he: thanto its underlying cause

' Other short screening mechanisms consid-ered appropriate for use in an acute caresetting are the A nupfer method (19d4) andthe CAGE method (Ewing 1984)

A LC OHM 11 LA I TH & RESEA RC II WEALD

MANAGING ALCOHOL-RELATED

TRAUMA

The results of bath laboratory testsand patient self-reports are criticalnot only for identifying an underly-ing alcohokehited disorder but alsofor treating those presenti:_g withinjuries, according to Soderstrom,who discussed early patient man-agement, and Paul Woolf, M.D., ofthe University of Rochester MedicalCenter, who discussed physiologicalalterations that may result fromalcohol use or abuse.

In addition to the possible confu-sion of head injury with intoxica-tiou, Soderstrom noted thedifficulty with identifying intra-abdominal injury. "To us," he said,"if a patient appears to be intoxi-cated, that is a reason to do a peritoneal lavage . . . [irrigation ofthe abdomen] or a CT [computer-ized tomography] scan to look forinternal injuries. Patients who seemto be a little drunk may have nosigns or symptoms pointing to in-ternal injuries. Some of those pa-tients may go into shock hours laterbecause of a fractured spleen or acracked liver."

Soderstrom also noted problemsof thrombocytopenia (a decrease inthe number of blood platelets) inpatients who have abused alcoholon an acute basis. With the cessa-tion of alcohol use on admission, arebound thrombocytosis (an unusu-ally high platelet count) may occurabout I week after admission. Be-cause both conditions may producesurgical complications, it is impor-tant to monitor diligently a pa-tient's vital signs, cardiac function,and serum electrolyte levels duringoperative and postoperative care.Complete blood counts (with plate-let determinations) and coagulation

Vol.. 13, No. 2, 1989

studies also should be a regularpart of patient care.

However, the most common sur-gical complication among patientswho are intoxicated precedes actualsurgery, according to John Stene,M.D., Ph.D. Stene, an anesthesiol-ogist who works with Soderstromat MIEMSS, reminded symposiumattendees that alcohol potentiatesanesthesia, so that when a patient isintoxicated, the level of anesthesiashould be reduced. Alcoholics whoare not intoxicated, on the otherhand, require much higher levels ofanesthesia. Stene also called atten-tion to problems resulting from theinteraction of alcohol with otherdrugs. He cautioned that mosttoxicology tests are crude and failto detect all drugs of abuse.

Other common difficulties withtreating alcoholics include cardiacand immune defense system prob-lems, hypothermia, and, of course,withdrawal, Soderstrom said. Delir-ium *remens (DTs), the most criti-cal form of alcohol withdrawal, hasa mortality rate of 4U percent it Lettuntreated. Soderstrom describedthe need for emergency rooms andtrauma centers to make use of "upfront" indicators of persons at riskand defined the presence of anytwo of three indicators as predictiveof the need to prophylax againstDTs: history of DTs or prior with-drawal syndrome, liver cirrhosis,and recent heavy drinking.

The problems encountered byphysicians in dealing with padentswho have used or abused alcoholhave heightened the interest of re-searchers in physiological altera-tions resulting from various levelsof alcohol consumption. Woolf,who addressed the ARUS meetingon alcohol's possible effects on

7

neuronal injury, suggested the useof circulating hormones, or neuro-humoral markers, to predict out-come in brain- injured patients. Toexplore this and other areas ofmetabolic research, discussantDavid Lewis Davies, Ph.D., of theUniversity of Arkansas, stressed thene J for clinicians to coordinatetheir research with that of basicscientists. Davies raised as an issuefor further exploration the possibil-ity that alcoholics are in some wayat greater risk for incurring trauma:"Is there some sort of metabolicdysfunction that predisposes themto higher susceptibility?" he asked.

Whether or not alcoholics are atgreater physiological risk for incur-ring trauma, they are at rir,k forgreater severity of injury. sympo-sium presenters agreed. Accordingto Soderstrom, research findings'lave disputed the widely held per-ception that persons who areintoxicatedand therefore relaxedare better protected against seriousinjury at the time of an accident(Wailer 1987; Roizeu 1985). Walleralso stressed that persons with highBACs are more likely to be alco-holics and more likely to die at thescene of an accident than thosewith low BACs, a pattern he notedto be consistent across all types ofinjury. "Our concern, however, isnot with identifying alcoholism perse," Waller added, "but with identi-fying it among those who will liveand, therefote, who can benefitfrom such identification andintervention."

IN 11.RVENING V IIh !MUM. D

AI otun s

"Every trauma expert must be aninterventionist," stated Max Schneid-er, M.D., past president of theAmerican Medical Society on Alco-

171

DEPARTMENTS

holism and Other Drug Dependen-cies. Schneider, who presented apaper entitled "Intervention andFollowup of the Alcoholic ItmumaPatient," lamented, ". . . becauseit is really a stigmatic disease . . .

we get the feeling [diagnosis ofalcohol dependence] is more anaccusation. . . . we becomeenablers."

Reporting on the medical studenteducation program at the Univer-sity of California-Irvire, Schneideradded that 30 percent of the juniorand senior media students areadult children of alcoholics. (Thisfigure conforms with an earlierestimate by Waller that one-fifth toone-third of all U.S. physicianscome from alcoholic families.) Ineither their junior or senior yeas,the California medical studentswork closely with the addictioneducation program, after which 3percent enter treatment and 12 per-cent request assistance for interven-tions with family members. Effortsof this sort, claimed Schneider, mayhelp overcome reluctance to screenand refer aicohoiic patients totreatment.

Schneider reviewed four types ofinterventi,,,i, including "self-intervention," which occurs onlyrarely when an injured patient sud-denly realizes that a mood-alteringdrug such as alcohol has contrib-uted to the traumatic event. Al-though initiated by the patient,self-intervention requires the medi-cal team to stand ready to direct thealcoholic to appropriate therapy.

The three other forms of interven-tion may be initiated productively byacute care physicians. One-on-oneintervention by a physician, nurse,or counselor may be performed inthe emergency room with both am-bulatory clients and persons ..:drnit-

172

ted to the inpatient unit, Schneidersaid. The interventionist shouldfurnish disliarged patients withspecific diaoostic information, suchas the written comment, "Your BACwas [.15], indicating the likely pres-ence of a treatable disease." Discus-sion of the diagnosis may be heldwith the patient's family, and anappointment may be made for thepatient's retun.. On the return visit,the patient is counseled to the pointof referral to an alcoholism treat-ment program.

Intervention patterned after theJohnson Institute model (Johnson1986) also may be performed in anacute care setting. The Johnsonmodel convenes family membersand others significant to the alco-holic and results in a specific planfor alcoholism treatment. Schneidercautioned that even in the busy envi-ronment of a trauma center or emer-gency department, the interventionmust be conducted privately.

For patients with whom earlierintervention and prior alcoholismtreatment have failed, reinterven-non is necessary, Schneider said."This is a chronic disease withexacerbations and remissions," henoted. "The seeds arc.. sown [byintervention] and may take weeksor months or years to grow."

Schneider emphasized that allpersonnel in emergency depart-ments and trauma centers should beknowledgeable about the processesfor intervention. Physicians, c,,un-selors, nurses, clergy members, andsocial workers ". . . should beaware that there is something thatnot only can he done, but must bedone," he said. Citing a program atBrown University, Schneider recom-mer ti-u a team approach. Brown's"A Timm" consists of nurses and

unselors who circulate thiough-

out all departments of the hospital,alerted to patients with possiblediagnoses of alcohol dependence.The A-Team, which includes recov-ering alcoholics, actually conductsthe interventions. Nevertheless,Schneider concluded, "It is thephysician in the trauma center, thephysician in the emergency depart-ment, who must take the leadershipand, historically, we have been re-luctant to do so."

UPDATING KNOWLEDC.E AND ATTITUDES

The relationship between physicianattitudes and patient care was arecurrent theme throughout theARUS workshop. In his openingpresentation on diagnosis of alco-holism, Waller claimed that diagno-ses are often overlooked or evenactively avoided because physiciansfeel a ". . . sense of frustrationand futility about the disease. Theydo not know what resources areavailable . . and they errone-ously believe that little can be donefor me alcoholic. . . ." Wallerattributed some of the deficits inphysician knowledge and attitudesto alcohol-related problems in thephysicians' own families.

Discussant Magruder-Habibsuggested that many physiciansremain unconvinced that alcohol-ism is a disease at all, A positionthat removes their responsibility totreat it: "The patient does not wantto admit that he or she is alcoholic.It is a wonderful collusion. Nobodyneeds to address the problem andeverybody comes out okayexcept,of course, in the long run."

Referring to recent studies ofphysician attitudes (see, for exam-ple, Soderstrom 1987; Lowenfels etal. 1989), Fielding speculated thatself declared attitudes may varysubstantially front actual behavior.

ALCOHOL HEALTH & RESEARCH WORLD

"In many senses," Fielding said,"the physician is in the same cate-gory as the patient, a victim ofsomething . . . we do notunderstand."

Magruder-Habib called attentionto a study in progress that examinesthe behavior of physicians who aresupplied with screening results in-dicative of likely alcoholism .1 theirpatients.' This blind study is ex-pected to examine physician atti-tudes and behaviors in a mannerthat removes the possible bias ofphysician self-reports.

Even when physiciansare kn 9wledgeableabout alcoholism andits treatment . . .

competing prioritiesforce them to makedifficult choices.

Even when physicians are knowl-edgeable about alcoholism and itstreatment and have positive attitudestoward alcoholic patients, compet-ing priorities force them to makedifficult choices. According to onesymposium participant, when adiagnosis of alL3holism is incorrect,malpractice litigation present. aformidable threat. When a BAC testreveals substantial alcohol involve-ment, medical treatment may becomplicated by legal procedures.And when injuries are reported asalcohol related, insurers may refuse

' Kathryn Magruder-Habib, Ph.D may becontacted concerning the study in progress atthe Veterans Administration Medical Center,Psychiatry Service, 508 Fulton Street, Suite116 -A Durham, North Caro'ina 27705

to reimburse fcr medical care. Con-siderations of this sort confound thedecisionmaking of even the bestintentioned emergency physicians.

"What are the real solutions?"asked Fielding. "We have to iden-tify where the fixed points are. . . go to the hospital governingbodies, the medical executive com-mittees. and ask them to draw updepartmental guidelines, remember-ing that physicians may be criti-cized if they do not Identifypatients at risk. . . . Having iden-tified patients with significantblood alcohol levels . . . theyneed to allow the lay counselingservices, the paramedics, navethe blood alcohol results on a dailybasis so they can get involved withthe physicians and take that infor-mation to the bedside. . . . I thinkwe ought to be requesting that this. . . topic come into the qualityassessment of all institutions. Thenwe can get on with education forpatients, physicians, legislators, andthe media." Other practical solu-tions offered by ARUS symposiumparticipants included efforts toinform the insurance industry ofthe clinical significance of alcoholtesting and improved networkingbetween acute care personnel andcommunity alcohol treatmentresources.

In addition to expanding andrefining basic, biomedical, andepidemiological investigations,-,ymposium participants recom-mended continued Analysis of phy-sician attitude , with particularattention to the specialties of sur-gery and internal medicine. Urgingfurther research on physician atti-tudes, Waller asserted, "The payoffwill be not just better treatment forour patients, but better living ofour own lives."

ANN M. BRADLEY

REFERENCES

American Psychiatric Association Diagnos-tic and Statistical Manual of Mental Disor-ders, Third Edition, Revised. Washington,DC: the Association, 1987.

Committee on Trauma Research Injury inAmerica: A Continuing Public HealthProblem. Washington, DC: National Acad-em; Press, 1985.

CYR, N ND WARTMAN, S. The effectivenessof routine .,creening questions in the detec-tion of alcoholism. Journal of the AmericanMedical Association 259:51-54, 1988.

EWING, J Detecting alcoholu,m: The CAGEquestionnaire. Journal of the AmericanMedical Association 252 1905-1907, 1984

FULLER, R.; LEE. K , AND GORDIS E. Validityof self-report in alcoholism rest.arch: Re.ultsof a Veterans Administration cooperativestudy. Alcoholism: Clinical and Experimen-tal Research 12:201-205, 1988.

JOHNSON, V. Intervention How To HelpSomeone Who Doesn't Waal Help. Minne-apolis. The Johnson Institute, 1986

KNUPF, R. G. Risks of drunkenness: A com-parison cif frequent intoxication indices andof population subgroups as to problem risks.British Journal of Addiction 79.185-196,1984

LoWENEEI S. A , SODERSTROM. C.; AND ZUSKA, J

Alcohol and injury Surgical knowledge andatm ides Alenhnl bionIth A peconrch13.91-92, 1989.

Rocki_r-r, I , AND PUTNAM, S Alcohol andunintentional injury B.fyond the motorvehicle Rhode Isli nd Medical Journal69 419-424, 1986

ROIZEN J. "Alcohol and Trauma." Paperpresented to the International Symposiumon Alcohol-Reicued Casualties, Toronto,Canada, 1985

SODErS, ROM, C , AND COWI EY, R A natior 1

alcohol ?nu trauma center survey, Missedopportunities, failures of rcspoosibility.Archives of Surgery 122(9) 1067-1071, 1987

WAI I ER. J Injui y as di,ease. AccidentAnalysis and Prevention 19 !3 -20, 1987.

WATSON. C , Til I ESKJOR. C , HOODECHECI\

Sc HOW, E., PUCE! . J ; AND JAC OBS. L Doalcoholics give valid self reports? Journal ofStudies on Alcohol 45.344-348, 1984

World Health Organization InternationalClassification of Diseases, 9th Revision. VolI Geneva, Switzerland WHO, 1977

VoL. 13, Na 2, 1959 G, t i 173

DEPARTMENTS.

InternationalPerspectivesAlcohol-Related Trauma inMexico

The presumed relationship betweenalcohol and tri..ima is an importantpublic health topic in Latin Amer-ica because trauma is a major causeof male mortality among severalcountries of the region. In Mexico,for example, "accidents, poison-ings, and injuries" are the mostfrequent causes of mortality amongmen aged 15 to 44 years (Rosovskyand Garc'a 1988). Until recently,however, data documenting therelationship between alcohol andtrauma in Latin America I. beenscarce (Medina-Mora anc nzales1988).

During the last five years, Mexi-can researchers have made rapidprogress in collecting these data.Led by staff members of the De-partment of Epidemiologic andSocial Research of the MexicanInstitute of Psychiatry, research onalcohol and trauma in Mexico hasadvanced from field tests of datacollection techniques to interna-tional collaboration that comparesalcohol involvement in trauma inMexico City to findings obtainedfrom California emergency rooms.

USE OF STATE. ATDORNLV RECORDS ON

ALCOHOL. AND TRAUMA

According to Haydee Rosovsky ofthe Mexican Institute of Psychiatry(1988), the earliest source of Mexi-cali data on alcohol involvement intrauma is the records of the StateAttorney in the Federal District ofMexicoa jurisdiction similar tothe District of Columbia in theUnited States. The State Attorn ymaintains field offices in emerg .ncyhospitals (hospitales de urgerv-ic5)of the Federal District's Medic ilServices, where a resident doctor

174

documents the physical conditionof patients who may eventuallybecome involved in criminal prose-cution_ or accident investigations.The physicians conduct clinicalexaminations of these subjects,similar to examinations performedat police stations. The examinationsinclude determining alcohol in-volvement in the patient's injury orillness. The office of the State At-lirney thus records probable alco-hol involvement in many emergencyroom casesbut the documenta-tion is limited by the lack of labora-tory tests that provide objectivemeasurement of blood alcohol con-centration (BAC) (Rosovsky 1988).

In 1985, a research team from theMexican Institute of Psychiatryattempted to use the records of fouremergency hospitals to documentthe scope of alcohol-related traumaexperiences: in Mexico City (MasCondes et al. 1986). The data sug-gested that approximately 12 per-cent of all cases admitted to thosehospitals in 1983 and 1984 resultedfrom arcidentc occurring under theinfluence of alcohol. The case re-cords also indicated that approxi-mately 5,000 victims of intentionalviolence annually were admitted tothe four hospitals under the influ-ence of alcohol. These vicniseffectively increased the a. uhol-related case load of the emergencyhospitals tc, more 'Ian one-sixth ofall admissions during 1984.

IMPROVING DATA COLETCDON ON

AI c °Hui-RELATED TRAI [MA

The epidemiologists of the MexicanInstitute of Psychiatry recognizedthe limitations of relying on datafrom the office of the State Attor-ney to investigate the re' Aionshipof alcohol and trauma. Their initialefforts to improve data collection

and analysis focused on the follow-ing objectives (Rosovsky 1988):

to describe existing means ofdocumenting the role that alcoholconsumption plays in accidentsand crimes brought to the atten-tion of medical and law enforce-ment authoritiesto develop and test a methodol-ogy to improve evaluation of theimportance of alcohol consump-tion in these casesto collect and analyze eata onsociodemog:aphic characteristics,drinking patterns, and previousalcohol-related problems of thepopulation involved in these cases.

The last of these three objectiveswas the topic of a study performedat the Xoco Emergency Hospital bystaff members of the Mexican Insti-tute of Psychiatry in late 1985 (Ro-sovsky and Lopez 1986). For a fullmonth, they interviewed every pa-tient who came to the attention ofthe onsite office of the State Attor-ncy bccausc of prc_lbabic alcol olinvolvement in the presenting in-jury. The interviews yielded awealth of information on pattern!,of co ration, history of alcoh31-related problems, and specific,drinking events prior to injury, asreported by the patients. The re-scarchers noted that most individ-uals in the sample were young menadmitted as a result of injuriessustained in fighting and that thetypical pattern of alcohol ccnsump-tion reported among those inter-viewed following fights wasoccasional binge drinkinc:, ratherthan more frequent consumption.

Rosovsky and Lopez (1986) ex-pressed concern that dependence onphysician observation to determinealcohol involvement was not suffic-

ALC01101 HFAITH & RIENtARCH WORLD

lent to identify all trauma victimswhose injuries followed alcoholconsumption. In their study, theyreported that under present condi-tions, a considerable nroportion orthe admissions to an emergencyhospital and to a police station wasnot examined by the physician toassess the presence of alcohol: Only61 percent of all patients at theemergency room and 39 percent atthe police station were examined,and the report of alcohol consump-tion in those cases was 7 percent atthe hospital and 15 percent at thepolice station. Simultaneously, theresearchers interviewed all personsand the proportion that reportedalcohol consumption prior to theevent was much higher: 18.5 per-cent at me hospital and 39 percenta the police station.

In 1986, the Mexican Institute ofPsychiatry took a major step for-ward in data collection efforts onalcohol and trauma by selectingpatients for study independent ofthe official process of case identifi-ratinn by renrpcentativpc of thejustice system. At eight hospitalemergency rooms in Mexico City,investigators from the Instituteselected subjects for breath sam-pling and interviews at randomfrom along all patients 15 years ofage and older admitted during asingle week. Breath samples weretaken immediately after admissionto obtain BAC measurement asclose in time as possible to the oc-currence of the presenting trauma.In October 1987, similar datalection was performed on all pa-tients 15 years of age and olderadmitted to three hospital emer-gency wards in the port city of Aca-pulco over the course of the entire

Vot 13, Na 2, 1989

month. A significant component ofthese data collection efforts wasadoption of a model for emergencyroom data collection instituted byCheryl J. Stephens Cherpitel,Dr.P.H., of the NIAAA-sponsoredAlcohol Research Group at Berke-ley, California (Rosovsky and Gar-cia 1988). The original Er.glishlanguage interview guide developedby Cherpitel was translated intoSpanish for use in Mexico, and themodel's study design and analyticdefinitions have been incorporatedin the protocols of the MexicanInstitute of Psychiatry's research(Cherpitel and Rosovsky 1988).

COLLABORATION LEADING TO CROSS-

NA1 IONAL COMPA AISON

Adoption of the standardized Cher-pilel model and its associated datacollection techniques by researchersin several countries, including Mex-ico, will permit cross-national com-parison of alcohol consumptionvariables among emergency roompopulations, using parallel methodsand data rnlit:rtinn inctrtimprtc.Some of the first fruits of this col-laboration were presented by Cher-pitel, of the Alcohol ResearchGroup at Berkeley, and Rosovsky,of the Mexican Institute of Psychia-try, at the annual meeting of theAmerican Public Health Associa-tion (1988). The presentation fea-tured findings from parallel datacollection efforts at emergencyrooms in Mexico City and ContraCosta County, California. Thecollaborative effort was funded inpart by NIAAA's Internationaland Intergovernmental AffairsProgram.

Cherpitel and Rosovsky (1988)reported significant comparative

findings on the characteristics ofthe trauma victims in the two coun-tries. Some of these differenceswere gender specific:

In tile Mexican hospitals, theratio of all injured male patientsto injured female patients report-ing alcohol consumption within 6hours prior to the injury wasnearly 5:1. In contrast, amongthe Contra Costa sample, theratio of injured males to femalesreporting alcohol consumptionwithin 6 hours prior to the injurywas less than 2: I (p. 29).While female emergency roompatients in California were morethan twice as likely as their Mexi-can counterparts to test positiveon the breathalyzer (p. 28), amongmale emergency rt.am patients,the injured in Mexico were morethan twice as likely as those in-jured in California to test positive.

Other cross-national differenceswere identified in patient self-reports "f tha norrrl'.! fretvency ofalcohol consumption amongtrauma victimssignificantly largerproportions of abstainers and infre-quent drinkers were found amongthe Mexican sample than amongthe Contra Costa sample (Cherpiteland Rosovsky 1988, p. 12).

The collaboration between theAlcohol Research Group ,.t Berkeley,the Mexican Institute of Psychiatry,and investigators in other countries,often aided by NIAAA, will contrib-ute to further refinement of investi-gative techniques. These techniques,in turn, yield increasingly accuratedata on the extent of alcohol- relatedpublic health problems throughoutthe world.

175

DEPARTMENTS

Correspondence on alcohol epi-demiology activities of the MexicanInstitute of Ps),,hi ttry may be ad-dressed to Havdee Rosovsky,M.P.H., Division de Investiga-ciones Epidemiologicas y Sociales.Instituto Mexic-oo de Psiquiatria,Antiguo Camio a Xochimilco No.1010, Huipulco, Mexico 22 D.F.,Mexico.

MICHAEL J. STOIL, PH D.REFERENCES

CHERPITEL, C.J. STEPHENS, AND ROSOVSKY, H

"Alcohol inptirin and Casualties. AComparison of U.S. and Mexico EmergencyRoom Populations." Paper presented at the16th annual meeting of Lne American PublicHealth Association, Boston, MA, Noveml,,.ri3 -17, 1988.

S CONDES. C.; MANRIQUE, A.; AND

RELA, C. Detcccion de problemas rela-cionados con el consumo de alcohol encuatro hospitales de urgencias del L SaludMental 9(4):10-14, 1986.

MEDINA-MORA. M.E AND GONZALES, LAlcohol-related casuIties in Latin America.A review of the literature. ln Giesbrecht,N.; Gozales, R.; Grant, M.; Osterberg, E.,Room, R.; Rootman, 1.; and Towle, L., eds.Drinking and Casualties: Accidents, Poison-ing and Violence in an International Per-spectir London: Routledge, 1)88. pp.68-83.

ROSOVSKY. H. Alr.ohol-related ca:malties and

crime in Mexico: Description of reportingsystems and results for a study In.Giesbrecht, N ; Gozales, R.; Grant, M ;Osterberg, E.; Room, R.; Rootman, 1 , andTowle, L., eds. Drinking and CasualtiesAccidents, Poisoning and Violence in aninternational Perspxtive. LondonP.outledge, 1988. pp 260-274

ROSOVSKY. H , AND GARCIA, G "AlcoholRelated Casualties ii Mexico: i ComparisonBetween No Populations " Unpublishedpaper p: -anted to the Alcohol Epidenuol-ogy Symposium, Berkelei,,, California, June5-11, 1988

ROSOVSKY, H., AND LOPEZ, J L Violencia 3,accidentes relacionados con el consumo dealcohol er la poblacion registrada en Ur,agencia investigadora del Ministerio Publicodel D.F. Salud Mental 9:72-76, 1986

176

SpecialPopulations

NIAAA Support for Studieson !'ispanic-ArnericansAmericans of Hispanic origin con-stitute the fastest growing ethnicgroup in the United States. Num-bering over 14 million in 1980, theHispanic population will surpassthe black American populationduring the 1990's, according tosome c mates.

Despite the growing numericalimportance of Hispanics, little isknown about patterns of alcoholuse, abuse, and depend Ice amongthe Spanish-speaking communities.There is consensus tl di: Hispanic-Americans are undcrserverl by treat-ment and prevention efforts, in partdue to culturally based barrierswithin tne Hispanic commurity.The absence of epidemiologicaldata on the extent and consequencesof r lhol-relate l problems amongHi.punic-Am-Nicans also contrib-utes to difriculties in providingappropriate services.

ong its other functions,NIAAA's Division of Biometry andEpidemiology (DBE) dbects theextramural research projam inalcohol epidemiology for the Insti-tute. "Extramural" research con-sists of studies performed byinvestigators from universities andother research institutions outsideof the Federal Clovernment. DBE-awarded grants on drinkingpatterns in Hispanic-Americancommunities respond to the impera-tive to increase knowledge ofalcohol-related public health issues.DBE is sponsoring four investiga-tions of Hispanic, !,:ohol use,which comprise 10 1, -ent of theDivision's active grants.

Explaining the importance of thisresearch, DBE program officerDavid Sanchez sugge:ts that analy-

sis of the effects of acculturationand assimilation on Hisp2-ic drink-ing behavior may have applicati.mto understanding changing alcohol

patterns of many immigrantgroups. Additionally, Sar nez notesthat the stressful transition fromvillage life t the complexity oflarge cities, experienced by manyadult Hispanics, also may affectalcohol use.

The role of alcoholism as a cop-ing mechanism to reduce stress isan explicit focus of the . rk ofJames Neff, Ph.D., and colleaguesie. the Department of Psychologyof the University of Texas HealthScience Center at San Antonio. TheDBE-supported research employsprospective methodology to com-pare drinking patterns and motiva-tions for drinking among adultMexican-Americans, blacks, andnon-Hispanic whites A major issuer the study is the diff-rcntiation ofthe effects of socioeconomic statusand subculture on the use of alco-hol to relieve psychological andemotional stress. In effect, thestudy seeks to respond to suchquestions as whether specific drink-ing patterns, including weekend"bilges," are influenced more byethnic varill-les or b!, the sharedvalue :t coworkers.

Interpretation of the findings ofthe Neff study may benefit from asecond DBE-supported analysis onpatterns of alcohol use amongM ,icon- Americans, conducted byM. Audrey Burnam of the RandCorporation in Santa Monica, Cali-fornia. Burnam is using an existingdata base (Hispanic Health andNutrition Examination Survey) thatinciudes alcohol consumptionpawl ,s of Hispanic-Americans(Christian et al. in press). An addi-

ALCOHOL HEALTH & RESEARCH WORLD

rid

p

tional source of comparison may bean earlier NI AAA-supported studyof drinking patterns amongMexican-Americans conducted bythe Alcohol Research Center atBerkeley, California (see Caetano1986-1987).

Variable definitions used in theBerkeley study have been adoptedby Gerald Gurin, Ph.D., and col-leagues at the His; anic ResearchCenter of Fordham Universit:, in asurvey of drinking behavior, non :s,and problems among Puerto Ricanadults in the New York metropoli-tan area. 'I as DBE-supportedstudy, performed with the help ofTempi! University's Institute ofSurvel, Research, is desigred toproduce basic epidemiological dataon Puc.,,. Ricans comparable tothat generated by previous surveysof Mexican-Americans, blacks, andnon-Hispanic whites. In aduition,Gurin proposes that the study find-

1 - 13, Na 2, 1989

is

pected increases in budges alloca-tions for DBE extramural research,may accelerate the pace of new;findings in Clis area of alcoholepidemiology. One potential topicfor new research is the identifica-tion of patterns within the Hispaniccommunities, including differencesin alcohol-related behavic,: amongCentral American, South Ameri-can, Mexican, and Cuban immi-grants, and descendants of thelong-established Hispanic com-munities of the southwesternUnited States. Bec use the home-lands of these distinct Hispaniccommunities are ....,.ociated withcharacteristic national patterns ofalcohol use, documentation ofdifferences in current use patterns

imay provide important information'. on the process through which<7 Americans in general become so-

cialized to consumption of alco-holic beverages.

Information on future opportun,1ties for DBE giant-supported inves-tigations of Hispanic-Americanalcohol epidemiology, including therequired application packages, maybe obtained by contac.mg DavidSanchez at the National Instituteon Alcohol Abuse and Alcoholism,Room 14C -26, 5600 Fishers Lane,Rockville, Maryland 20857.

MICHAEL J. STOIL, PH D.

REFERENCES

ings will enable analysts to test atheoretical model t. at relateschanges in the drinking patterns ofPuerto Ricans )n the U.S. main-land to gene:al celtural effects ofmigration and acculturation.

A more intensive methodologyemploying a community samplingprocedure to select Puerto Ricanmen for structured interviews char-acterizes the work of Merrill Singer,Ph.D., and colleagues in DBE-sponsored research at the Universityof Connecticut at Hartford. Inaddition to basic epidemiologicalinform- in, the Singer study willattempt to identify he "n^turalhistory" of drinking among ?uertoRican men, including family drink-ing histories, beverage preferences,and changes in quantity and fre-quency of consumption over time.

Sanchez ;relieves that the recentincrease in interest in Hispanicalcohol patterns, coupled with ex-

,

CAET,,NO, R. Drinking and Hispanic-American family life. Alcohol Health &Research World il(2):26-34, 1986-1987.

CHRISTIAN. C.; ZOBECK, T.; MALIN H.; ANCMITCHCOCK, D. Hispanic HANES: Generaldescription, methodological issues, andpreliminary finrlings. In. ,..piegler, D.; 'PaD.; Aitken, S.; E nd Christian, C., eds.A..oh9l Use Among U.S. Ethnic Minorities.NIAAA Research Monograph No. 18.DHHS Pub. No. (ADM)87-1435. Washing-ton, DC. Supt of Docs., U.S. Govt. PnnL.Off , in press.

177

Highlights fromthe 1987 National Drugand Alcoholism TreatmentUnit Survey (NDATUS)

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

I his at lc is hosed e ',I the tint; elltIlle,1llit;h1Nlas,P cati the I 9S7 Naticaial I); us; chid

Al( °holism t secamemi ('nit St's s CI (NI) All 11; e; earl\ published In tie %ninon,' Ins01551,

I ohol Abuse (mil 41e ccholism and theNational Inmtute on 1.), at, 4Inte A detailedspin! shuns IS is hedidt

pit late, this sear and es /// /7! al ,III,1111,

porn the Notroval ( lea, L;,'',11,( tot 11( "11,4(mil 1)1 ht; IMoi mutual P 1) Hoc 145Roe ks die S/!) 2/652 Pri sons ts !shalt, 1,, use

the slates rata rape should «Ita 1 's

I. reacus 1, Slins,m al lilt ,11 0/1,,i l 1)1,1011,0100

1)ah, S won ( SR In ot pot we,/ Hoo I ,St',et \41 Suite WO aquto4t,,r1 2tinto

Bs( MAW( 'AD INFORM ihrs

The National Drug and AlcohchsmTreatment Unit Survey (NDATUS)was first ccinduohd in 1974 by theNational Institute on Drug AbuseINIDA) and has been conductedevery 2 to 3 years since then In

1979, NDATUS was etypai Itoinclude alcohol', tu as well as drugabuse facilitie' since that time it habeen sponsored jointly by NIDA andthe National Institute on Alcohol

JOAN R IIARRLS, Pll I) and I S

1) COLIll LI?, PH 1) .SoiwiAnalysts wall the Alt Out(Epulennoiagu Data System,CSR, m orpc, Wed

Abuse and Alcoholism (NIAAA)NDATUS is a Yolultary sure that isdesigned to oe a census of all knowndrug abu-e ant'' alcoholism treatmentfacilities in the I aits:d States MIN

article is based on preliminary data onalcohol in treatment derived from the1987 NDATUS The full 1957 re-port, which will include data fromboth drag abuse and alcoholismfacilities, is scheduled to he pobli-hecilater this year Data on clients intreatment pertain to the point-pro. diem e date of Octok,r 30, 1957

The purpose 01 NL. NT'clS is toidentify all drug attrit,e and Icoholtsm

air:lent and prevention tacilitiesthroughout the nation, and to collectinformation regarding their scope,unhiation, and other chant( teristicsFacilities in both the public andprivate sectors are included,

gardless of the source of tundincsupport Unit identification anddescriptive information such asokkr,Jship and speciali/ed programsare collected from treatincnt andnontreatment facilities Fromtreatment urits, NDATUS alsocollects data :)',out the types ofservices provnies1, client capacity andcensus on the point-prevalence date,client demographic characteristics,

.0 , I

and fowling amounts and sources,The data are collected in

cooperation with the State Alcoholand Drug Abuse Agencies, whichassist in identrfying programs to hesurveyed, di triblitine forms toindividual lacilitics, collecting formsand answering responder qiestiory,checking and echimg chit, ' subnutting completed question

In a departure from pro, roekeys which required that tail , heidentified by a unique Gokernmcm-issued identification number, the1(1'87 NDATUS S accepted the States'

nr.sntificarton numbers and lucre

(101111110t1 of what constitutes ,

lot reporting piaposes In

-,'tore cases multiple -site facilitieswere repotted as a single unit(representing the parent orga-miation), in other cases each ',lie wasreported as a separate facilityAlthough this,,ination may affect thenumber of facilities, it has no effecton the total number nts re-ported

following, a brief s ,'ction on the to-tal number of facilan s reporting,including both treatment and pre-vention units, the remainder of thercport is restricted to dta facilitiesproviding treatment servicc ropes

ALCOHOL HI. ALTH & RESEARCH WORLD

addre,sed lit& number, of client,in treatment, hudgetAl caraLit and

utili/atiott rate,. number, of client, hfacilitL location or en, [Hutment andtype of treatment, client demographiccharacten,nc,, factlit coum Ind

client cen,u,b. facilit location,financial ,upport for treatment wr-vice, 11 funding ,ource, facilityoLLner,hip, intraLenou, drug uwr, In

treatn,..nt, number of client, in the 12month. ending %Lull the pout -preL a-lence date, and number, of factinic,and client cen,u, hL State \lorecomprehen,ive info:7,1,100n includingdrug client data LL ill tie pro, [(led inthe 1987 main finding, report to hepubh,hed later tin, ear

In moat caw, tabulation, of treat-ment data are bawd on f ac dole, thatreported either budgeted chic it ca-pacu or actual Client, on the point-preL alence date HoLLeLer table,,,hoLL it LI unit/anon rate, are ba,eddata front facture, that reported bud-geted capaL , thew table, \elude afew IaLditie, that reported actual(Them, but no hudg.Lttco capac

It al,o ,hould he ' hat data fot(dual item, arc netinle, 1)11\1

mg In the table, in , p itt thetotal number, of chi 1t , *ticetc , L hccau trf e \ I don ofoftwiL anon, for LL Inch art,

item, V), etc Ilt(I R110110,1

I able 1 ,hoLL nurnhei of

,er\nte akohol client, onthe pomt-preLalence date of October

I 9I,7 [hie ,onkt Lic dine, L

onIL alcohol tuner, I HO)alcohol and drug cllcnt. to fable I

It maL be ,Len that a 1,11l1:1 umber of( C, 4)01 wrLe both type, of

client, it, than re,trictim2 ,crLto alcohol', client, yid% (2 112)Numeru , more at dine, arede\oted to treatmen, a, a fat du%function

A, ,tated in the footnote to ilktable, f t nice, ma report mole thanone f unctron 1n regard to tret,'ment,preLennon/.'.(lucatio, and otIrer 1,01

VOL 13, No. 2, 1989

Table 1 Total number of alcohol faculties repr,rting to NDATUS by facilityfunction and facility orientation: October 30, 1987

;Ballyfunction

Alcohol-only

facilities

Combined All facilitiesalcohol

and drugfacilities

Treatment 1,708 4,083 5,791

Prevention/education 1,132 3,476 4 608

Other 946 2,492 3,43P

Number of facilities 2,132 5,360 7,492

NOTE As f:cemes may (Loon more than one function, columns do not sum to the total number of facilitesSOURCE NIDA and NIAM, 1987 National Drug and Alcoholism Treatment Una Survey

vor-aim

Table 2 Total numbers of allohol clients in treatment and number offacilities according to facility orientation: October 30,1987

Alcohol- Combined Allonly alcohol facilities

facilities and drugacilities

,bents 136,917 L13,696 350,613

Number of treatment facilities 1,708 4,083 5,791

SOURCZ NIDA and NI.AAA. 1987 National Drug and Alcoholism Treatment Uni, Survey

the NDATL S ,u1Lc, the iolloLL mgdefinition, hold for I at_ ilit function,

I reatment t unc non, refer to for-mal tortunied ,er, ice, for per min,\\ ho ha, e ahri,ed alcohol thew1:1-% ice, ate dc,Igned to alter

phL mental it ,octalfunction, of person, reccIL mg IreLien) \On anon ,e;-\ ee con,,n1-c red to h. treatmentPic Lentiomeducatior funct,oh,chide ac more, intended to ictluLcof it runnie the Inc Ides. e' of ncLLalcohoh,111 pt Thlern, and McnecanLe con,«rucnce, of olio' aLc of

alcohol

I HI \ I \II \ I l' 1111, \ \ I) VI II \I RI 11 %II \ 1

\ in fable 2 alcoholi,rntreatment Oct' III .1 I()1,11 ti

ti 791 LIL11111c, I 71)8 I.i 11-

th it pl()1(11:(10111% al(A)1,()I

v,'I% 1Le, and 4,081 thatpro, [(fed ,elL (cc, to both ding andalcohol client, I he,c fac dine, %Lew,crL mg a total of 1S0,61 dt ohol

Cj

client, on the point-Acme date of October 31), 1987

hit II D k) \

t 1/ L Ines K \II

Lompa I,011 of alcohol 11,2,11111(2M

fa- 111he, client, rn treatment, budgcted captic ILL , 1.1(.1utilliation rate hfacilit, orkutation on the point-pre, alcrice date of (ktohet 10, 1987,1, ,ItoL it in I able Budgetedapac ttL rebus, to the number of heti,

allocated foi ic,idconal alcohol ti:titmerit I the [writhe' of nonic,identralal, ohol client, L,ho could he ,erLed\\ i111 ,111,1hiC 1)}1\ and ,tall I:-,ource, I he mill/mum rare refer, toMc proportion of hud,:.etet1 Lai/AIMrc ma it tls,C on the po;ni -pie\atenor date 1 \an nation of the tahlchoLL, that alcoholi,m Lrc dine,

had the ImIlict,t mill/anon rate 1.13 4,

'or the number of c licit, LL ithin thelurti2etAl calla( it, of I ,(4,-1, fak_ihtle,

(hi the other nand, Ill lt)11111111C(1 alco-

hol and drug taciline,, the minm.i of

,I10)111)1 (_11C111, t: to budgeted

179

Highlights of NDATUS

capacity revealed a utiliration rate of79.8, a difference of 3 6 points

TREA DE110(.12

CHAR 4it '7 I RISTR

Taole 4 presents data on the demo-grarnic character', tics of alcoholclients Data for clients whose sex.race/ethnicity, or age we.: unknownare ex uded, resulting in a differingtotal number of clients for these c hal-acteristics

The age distribution of alcoholcheats is concentrated in the cate-gories of ages 25-44 years (55.0 per-cent) When the ag: percentages arecumulated horn younger to older,57 5 percent of those in treatment onOctober 30. 1987. were under 35years of age and 81 5 percent wereunder 45 years of age

It may be seen. however, in Table 4that almost one -fourth of all alcoholtreatment clients on October 30,1987, were female (23.7 percent) Byrace/ethnicity, black were somewhatoventpresented in terms of theircomposition in the general populationwith 15 4 percent of total alcoholtreatment clients While all m:nontypopulations represent :d 28 5 perLcntof such clients. overall, almost twothirds (71 5 percent) were white, aslightly smaller percentage than in thegenera! population

TN Pi' of (' SRIv N. 'I: is( if 1110\

The "type of are -salable relates tomoatientiresidential are with subLat-egones and outpanent/noniesidconalire Similarly facility 'man( n" ie-ates to ho,onal and nonhospital Lace

As might he anticipated. Table fishows that clicnts in hospitals wereevenly split between inpatient andoutpatient csr.: (5(1 8 nerc.ei and 49 2percent, respectively ) On the otherham!. :.-.1Lohol clients in not hospital

care settings show a distribution of10 0 pen cnt in inpatient/residential

1110

Table 3 Nuciber of alcohol treatment facilities, number of clients intreatmont, budgeted capacity, and utilization rate by facilityorientation: October 30,1987

Number Number Budgeted UtilizationFacility orientation of facilities.' of clients.' capacity rate 1

Alcoholism-only facilities 1,664 131,241 157,281 83.4

Combined facilities 3,963 206,687 759,056 79.8

Total alcoholism clients 5,627 337,928 416,337 81.2

I Excludes data from facades which did nr 1 report bucketed capacity for alcohol clientsSOURCE: NIA and NIAAA, 1987 National 114 and Alcoholism Treatment Unit Survey

mismaiP abrioarreammanaTable 4 Percent distribution of alcc.01 treatment clients by aux, race/ethnicity

and age: October 30, 1987

Sex , race! Alcoholethnicity and ape clientsMale 76.3romale 23.7

Number of clients 1 336,877

White 71.5Black 15.4Hispanic 9.9Other race/ethnlcity 3.2

Number of cliental 3:19,992

Under 18 years 6.418-20 years 6.421-24 years 13.725-34 years 31.035-44 years 24.045-54 years 11.755-64 years 5.265 years and over 1.7

Number of cliental 327,698

NC 1E: Perzrmtecais In distributions may not sum to 100 because of coo ind,n81 Excludes clients for whom sex, raosiethnicity, or age was not reportedSOURCE: NOA and N1AAA, 1987 National Diu% .uvi Alcoholism Treatment Unit Survey

Table 5 Number of alcohol clients in treatment by type of care and facilitylocation: October 30, 1987

Facility location

Type of care Hospital Non' aspital Total______ ___________

Inpatient/residentialMedk detoxification 4,955 s37 6,492Social detoxification 409 3,606 4,015RehabilratIon/recovery 13,906 23,833 57,739Custodial/domiciliary 488 2,200 2.688Total inpatient/residential 19,758 31.176 50,934

Outpatient/nonreAlduntial 19,115 280,564 299,679

Total inpatients and outpatients 38,873 311,740 350,613

SOURCE NIDA and NIAAA, 1987 National Drug and Alcoholitm Treatment Unit Survey

settings as opposed to 9() 0 percent inoutpatient /nonresidential settings

These same ivsults arc consonantwith a ieview of sonic of the inpa-tient/residential subcategories While

a"--iost or slightly more than three-tou -ths of all st c !lents w etc in re-bahlitation or iecoery programs( e \elude detoxification), theieare cid terences in types of detoxifies's-

tii,corun tit AITH & RESEARCH WORLD

....Tab 10 Number of alcohol treatment fealties and number of clients by facility

: Coto Ur 30,1967

Foolletia, Clients

, 4 ,--health um* 842 30,946

, .

1,163 55,5(70

41liteihilattly 60 2,945

lioiesaittleMery house 698 12,838

faQYfyr 701 21,705

2,004 173,912:-' 1,-.V:-..' _---'.

319 22,973

1 24

, 5,791 350,613

t °R V4 filoaholos loop* monlIMpordialSo hospitals, aftdOSIOrs000takcad`..,-... ..

1##Vil* thilialt",,'`v4 ilervlasibyflundtng source

;..%vly ,,,..,

aisalvIng wavy *OM Wilt Source:

Percent Facilitiesreporting

OVAlitsT(dietkilledkidee_

1345 023_. . 202 2,588

Lori107,680 6.4 1,852

ADA*1/4-10thipala 9A40 .an ,

... 179

C4her Fair:if:Oda = 76,957 4.5 530

Stalskocol Gni AllhOrd feesfor iiiint,* 78,830 4.6 805

PrivatidoriailOnia 25,906 1.6 1,274

Put* #WNere (e.g.. The XX,Food Silk ; 27,778 1.6 887

-atop TedaitZ(02.,CHAMPK- 145,746 8.5 1,368

aPrivads TN.'d Party (e.g., FetusCrotwalialfe *Md. HMO 592,447 34.6 2,209

(*int fees 236,531 13.8 3,727

Odw 64,752 3.8 927

TOTAL 1,712,069 100.0 4,949

NOTE: Amounts* funding some coupons' may not *um total bow, of rounding. The martyr of familiesreporting dose not opal to total of Wiliam mooning mono funding mows Weans of fo Mau recOvingfunding from roullpla tomesSOURCE. NUM and MAAA.12117 Motional Onig and Akoholion Traatmont Unit Survey.

Wm as appropriate for the facility lo-cation. One-fourth of clients in hos-pital/mpanc settings were receivingmedical detoxification. which rs theuse of medic:amr under the super,'sion of medical personnel in a hospi-tal or other 24-hour-care facCity

VOL. 13, Na 2. 1919

Only 4 9 percent of clients in non-hospit d settings were recek mg suchcare At the same time 116 percentiris opposed to 2 I percent) of clients

nonhospital location received so-

cial detoxification sery ices. wVa, h in-volve the s:stein tic reduction Or

elimination of the effects of alcohol inthe body on a dreg-free base'

F'A ii tit Lo( 4.110.

It may be seen from Table 6 that out-patient fa represented 34 6percent of all alcohol treatment

facilities, but served 49 6 percent ofalcohol clients on October 30. 1987.

FINANCIAL. SI PPOR I FOR

TRFA I %M", i SF It%

Alcohol treatment facilities reported$1 71 billion in total financial supportfor alcohol services for their fiscalyears including October 1987 (Table7) Private third-party payers, such asBlue Cross/Blue Shield and HMOs,provided the largest '.hare of financialsupport for alcohol treatmentservices, accounting for 34.6 percentof such funds. When these sourcesare coupled with client tees, the twosource~ account for 48.4 percent ofreceipts for alcohol care State gov-ernment funding so6R:es representonly 20 2 percent of all receipts foralcohol treatment

()WNLRSHIP Tto x %U. 's I

ILIIIFS

Of the 5.791 alcohol treatment facili-ties that reported NDATUS. 65 5percent were privately os,.ried, non-profit facrlit,es (Tahle H Thesefacilities accounted for 57 6 percentof alcohol clients in treatment on thepoint-prevalence date Facilitiesowned by State and Local govern-ments accounted for higher propor-tion~ of alcohol clients than their rep-resentation in sheer numbers. whichsuggests that these facilities hadLuger numbers of such clients. onaverage. than those in other owner-ship categories

CI RN I S WHO WI RI

IN I R 1% NOI URI

CommensLrate with present concern,regarding :ire spread of AMS, treat-ment lacilities were asked t )eportthe percentage of their cheats w'm

18

Highlights of NDATUS

were intravenous drug users OVERT,at the time they started treatmentThis item is relevant for. data reportedin the alcohol section of the surveybecause of alcohol client, v'ith sec-ondary drug problems

A iota! of 14,464 alcohol clientswere reported to have been in-travenous drug users at the time they

entered treatment This figure repre-sent,, 4 I percent among alcoholclient, (1-1,464 1VDUs in 350.613alcohol clients)

NI Nilif v of CI IF S TRI' I I) IN I laP,st 12 111oNity,

Histors, ally, NDATUS has collectedclient census information solely for a

Table 8 Distribution of alcohol Vestment wines and clients by facilityovntemittp: October 30,1987

Ovnisrehip Facilities Clients

Numbs,' Percent Number Percent

Private torpolit 900 . 15.5 42,878 12.2

Private nonprofit 3,794 65.5 201,789 57.6

Stale/Local 90v..rnment 934 16.1 87,344 25.0

Federal government 183 2.8 18,402 5.2

Total 8,791 100.0 350,613 100.0

PotoantioN dianitulicavimay not sanin400110aNeset coundina.SOURCE: NIORaniiNkoM, 11187 WW1 Owe and Aloonallom Treatment Unit Savoy.

particuLi point-prevalence dateStai king v,ith the 1987 NDATUS,however, questions regarding theunduplicated ,ounts of alcohol clientstreated in the 12-month period endingOctober 30, 1987, have been added.Data reported to NDATUS on thisnew variable indicate that in the 12months ending October 30. 1987, atotal of 1,430,034 alcoholism clientswere treated at 5,582 facilities

DAlvliN SI %If

State-level data on alcohol ti eatmentfacilities and clients ia treatment onthe point-prevalence date of October30, 1987, are shown in Table 9 Cal-ifornia andNev, Yolk together ac-counted for slightly more than one-fourth cif all clients in treatment atthe 5,791 reporting tacilthes.

1111111111111MMINIMINEM.,

Table 9 Number of alcohol treatment facilities and number of clients In treatment by State: October 30,19J70: ;,. Fullness Clients State Facilities Clients

Alabama 44 1,491 Nebraska 107 4,435Alaska 30 1,293 Nevada 40 777Arizona 75 3,814 New Hampshire 53 2,401Manses 46 1,953 New Jersey 155 8,857California 880 63,177 New Medco 47 4,015

Colorado 161 8,681 New York 398 36,126C winecticut 109 3,4/1 North Carolina 98 6,331Delaware 17 1,393 North Dakota 343 1,671Dist. of Columbia 13 1,244 Ohio 2:1V. 12,813Florida 197 11.783 Oklahoma 53 2,431

Georgia 52 5,932 Oregon 130 7,376Hawaii 30 738 Pennsyl'enia 328 14,684Idaho 28 1,332 Rhode I, ,o 41 2,760Illinois 201 12,523 South Carolina 51 10,299Indiana 98 5,380 South Dakota 29 1 469

Iowa 94 3,398 Tennessee 55 3,116Kansas 74 2,596 Texas 228 5,414Kentucky 130 5,106 Utah , 39 4,254Lc idelana 77 5,146 Vermont 19 1,082Maine 40 2,319 Virginia 80 7,501

Maryland 152 10,333 Washington 99 9,550Massachusetts 166 12,1. -9 West Virginia 22 3,186Michigan 208 12,031 Wisconsin 130 6,856Minnesota 139 2,481 Wyoming 23 956kilesiulppi 64 =1,935 Puerto Rico 24 3230

Missoud 94 3,976Mr .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, theNational Institute onAlcohol Abuse andAlcoholism (NIAAA)

asked the Iistitute of Medicine(IOM), an agency of the NationalAcademy of Sciences, to review andassess the status of alcohol research.The resulting report, Alcoholism,Alcohol Abuse, and Related Prob-lems: Opportunities for Reseych,provided the first comprehensivereview of alcohol-related researchfor scientists, planners, policy-makers, and other interestedpeople.

The pace of alcohol research hasaccelerated dramatically since thereport was released in 1980. Duringthat same year, as its first decathwas drawing to a close, NIAAAsupported a total of 167 researchprojects at a combined fundinglevel of $22.2 million. By 1987, thenumber of NIAAA-supportedresearch projects had increased to387 and the total funding to $71.2million.

Because of the opportunitiesprovided by advances in alcohol-related research since 1980, NIAAAagain asked the Institute ofMedicine to review new scientificknowledge, ssess current researchactivities, and identif!, he mostpromising areas to pursue over thenext 5 years.

This assessment will result in tworeports, one addressing the causesand consequences of alcohol-related problems and the other ad-dressing prevention and treat-ment. The first report, entitledCauses and Consequer.:es ofAlcohol Problems: An Agdi...!:., forResearch, was issued in 1987. Whatfollows is a review of that report.The second report is scheduled tobe ,ompleted in the fall 1989.

The report on causes andconsequences was prepared by a10-member group of scientists, theInstitute of Medicine Committee

Alcohol-related research lias accelerateddramatically and made many advancesover the past decade

Vol,. 13, Na 2, 1989

A New Agendafor AlcoholResearchThe Institute of Medicine Reports onCauses and ConsequencesA Summary

4

183

10M Report

for the Study of Alcohol- RelatedProblems, chaired by RobertStraus, Ph.D., of the College ofMedicine of the University ofKentucky.

The review contains some tech-nical terminology. As an aid to thereader, a short glossary is includedat the end of the summary. Limitedcopies of the full IOM Report areavailable by -Thing: Mary Dove,National Ins ite on AlcoholAbuse and Aizoho lism, Park lawnBuilding, Room 16C-I4, 5600Fishers Lane, Rockville, Maryland20857.

MAJOR RESEARCH QUESTIONS

According to IOM's study of thecauses and consequences of alcoilolproblems, "Ways in which peoplerespond to alcohol, varied capaci-ties to drink safely, and relativerisks for development of alcohol-related problems pose major ques-tions for research, The study ofdrinking behavior and the personaland societal consequences ofalcohol use requires conceptualapproaches that accommodateknowledge from many biological,behavioral, and social sciencedisciplines."

The report summarizes what aretermed "exciting advances inknowledge" in four areas:

identification of areas of cellmembranes with differential sen-sitivities to alcoholidentification oi risk factors thatdivide the alcoholic populationinto subpopulationseffects of the context of drinkingand the drinker's expectationson drinking behavior andconsequencesclarification of the relationships%)etween alcoholism and othertypes of psychiatric problems

Altogether, these advances arelinked to the increase in support foralcohol research. They providerefinements of the knowledge base

184

needed for progress in prevention, panel's recommendations for futuretreatment, and lehabiiitation.

POLICY RECOMMENDATIONS

't he 1980 report emphasized thecosts associated with alcohol abu-eand the need to attract scientifktalent to alcohol-related research.The new report recognizes the workof researchers whose activities meritfurther support. Several policypoints are highlighted:

Special genetically developed (anddeveloping) onimal lines shouldbe made available to the alcoholresearch community, and fundingfor this activity should bestabilized.Funding must continue for quali-tative and quantitative socialscience research. Retrospectivedata analysis or reanalysis shouldcontinue to be encouraged.The value of the computerizedabstract service provided byNIAAA should be enhanced witha thesaurus.'Diverse groups of investigatorsshould coordinate their stu.ilesincorporating registered subjects

om the general populationand high-risk groups to permitcost sharing and to correlateobservations.To interpret biological and behav-ioral science approaches andknowledge, thought should begiven to training a cadre of re-searchers with the appropriate;-,alytic and critical skills.Communication and coordinationamong Federal agencies interestedin research on alcohol znd itsimpact on society should beimproved.

Following its two introductorychapters, the report presents 10chapters of reviews and recommen-dations. These 10 chapters are sum-marized below, highlighting the

' The Is11/1.1/1 data base is now online withBRS Information Technologies, In" , and athesaurus is being developed

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research.

Quantifying the impact of alco-hol (Chapter 3). Data on alcohol-related morbidity and mortalityvary widely. For example, estimatesof the prevalence of alcoholism inhospitalized patient populationsrange from 9 to 55 percent. Suchextreme differences reflect varia-tions in the reporting methods. Onebasic difficulty 13 the lack of a trut,consensus on the definition ofalcoholism.

In treatment settings, variationsin definitions give rise to differ-ences in diagnostic criteria. In addi-tion, a physician may be reluctantto enter alcohol-related problemson a patient's record. In othercases, health professionals mayneed to be alerted to the role alco-hol can play in the patient's illness.It is not yet known, in fact, justhow large a role alcohol playsin muitiple-cause diseases andinjuries.

Estimates of annual alcohol-related mortality range from 69,000to 20.),000. Tne relative youth ofthe vit.tims is underscored by dataon the years of hie lost. Reports for1983 estimated that an average of20 years of life was lost by thosewho had died before age 65 fromalcohol-related causes.

Speciiic, quantified measures ofthe full social Impact of alcohrelated problems are even moredift cult to obtain than reliablemeasures of morbidity and mortal-ity. Alcohol abuse has been esti-mated to affect the families of 56million American adults.

An important aspect of alceolabuse is its cost to society. NIAAA,assisted by the Research TriangleInstitute, estimated that the socialcost of alcohol abuse in the UnitedStates was $89 billion in 1980. Theprojected estimate for 1983 wasnearly $117 billion.

The report contained the follow-ing epidemiological researchrecommendations:

ALCOHOL HEALTH & RESEARCH WORLD

study the bioiogicai and socialmechanisms leading to individualand group di 'ferences in suscepti-bility to alcohol-related problemscollect more extensive and accu-rate information on the prey--'enc.. and the role of Alcohol inaccidents, especial]; as alcoholinteracts with other drugs andwith other variables such as agedevelop more accurate estimatesof the prevalence of fetal alcoholsyndromedevelop more accurate estimatesof alcohol's contribution to a!!causes of death and study theextent to which alcohol's contri-bution is underreporteddevelop a consensus definitionand quantitative measurements ofthe adverse impact of excessivedrinking on victims, especially onchildren and spouses of alco-holics and on families of victimsof alcohol-related accidents.

Biochemistry of ethanol metabo-lism (Chapter 4). The starting pointfor understanding individzial physiological responses to alcohol is thestudy of th- enzymes that metabo-lize ethanol. Thus far, variations inthe form and the activity of oneenzyme, aldehyde dehydrogenase,have been linked with alcohol-relazed behavior and problems.

The structures of ke ;' enzymes areknown, and the DNA encodingsome of the subunits has been iso-lated and cloned. Studies of en-zyme expression will be advancedtr.; using the DNA clones as probesfor new information.

The IOM committee .nadethe following related researchrecommendjtions:

continue to study the genetic loc.;for alcohol dehydrogenase andaldehyde dehydrogenase to deter-mine how these enzymes areregulatedstudy the hybrids of hepatomas

Vol. 13, No. 2, 1989

and normal human cells to fur-ther delineate liver- specific geneexpression and to provide a poolof cells for noninvasive clinicaltestsmeasure the expression of mes-senger RNA or use antibodies toestimate protein levels to clarifythe control of enzyme synthesisand the subunits' activities withincellsstudy mutant animal modelsthat lack ore of the ethanol-metabolizing enzymes to discerntheir responses to and metabolismof ethanol and possible enzymeparticipation in neurologicalfunctions.

Animal models for research(Chapter 5). Specially bred animalmodels are a' ailable for research onalcohol-seeking behavior, on sensi-tivity to tl:e narcotic effects ofethanol, on a tendency to developtolerance to ethanol, and on thepropensity for withdrawal seizures.These developments confirm thatalcohol-related behavior is partlycontrotled by "constellations ofgenes."

Analysis of the behavior of in-bred mice has revealed three sepa-rate clusters of variables in nervoussystem sensitivity to ethanol. Indi-vidual diffelences can occur in one,two, or all three of these areas.

Some researchers are using se-lected animal models to learn whichbrain regions are involved in spe-cific behavioral effects of ethanol.In other animal studies operantconditioning techniques are beingused to study the reinforcing effectsof drinking.

Research in the following areas isrecommended:

study the effects of ethanc: onreward systems in the brain inanimal groups that differ :n theiralcohol-seeking behaviordevelop new animal models to

test the generality of previousfindings (possibly through recom-binant DNA techniques, usingexisting stable models)study the interactions of ethanolwith vasopressin, opioid peptides,and thyrotrop'n-releasing hor-mone in animal groups that differin nehavioral responses to ethanolstudy the effects of pharmaceuti-cal agents on alcohol-seekingbehavior, on the development ofalcohol tolerance, and on tenden-cies toward alcohol dependence(if the results are promising, hu-man studies should follow)evaluate gains in knowledgeabout alcohol-seeking behaviorfor implications for humans (forexample, do reinforcing proper-ties of alcohol differ betweenchildren of alcoholics and children of nonalcoholics?)use alcohol-preferring animals instudies of medical disorders asso-ciated with chronic alcoholconsumption.

Neurosciences (Chapter 6). Un-like other psychoactive substances,ethairol does not act by bindingwith a specific set of receptor mole-cules in the brain. Therefore,neuroscientists must study the ef-fects of ethanol on cell membranes,nn pathways for transmission ofnerve impulses, and on p trticipat-ing agents (e.g., calcium ions, cy-clic AMP) within cells. Scientistsare examining both vertebrate andinvertebrate systems in the labora-tory and studying t: physiology ofalcohol-related behavior in bothexperimental animals and humans.They are striving to relate ethanol-induced changes in neural activityto observed changes in behal 'or.

Acute doses of ethanol "fluidize"cell membranes; however, afterchronic ethanol treatment. themembranes become more rigid.Restricted regions of the membraneare nsitive to ethanol. A prime

165

IOM Repot t

area ,..)r research is a possible rela-tionship between these membraneeffects and alcohol intoxication,r.linforcemet t, tolerance, ordependen e.

Effect ve dos o' ethanol appearto inilaence events in some neuralpathways in the brain. In addition,rapid gain. in understanding themodulating roles of ions and otheragents within cells and cell mem-branes have opened new avenues inalcohol research. New techniquesare being used to study inter-actions of ethanol with these cellcomponents.

Research opportunities in neu :o-physiology include electrophysio-logical studies of brain activity inhuman subjects and to complementother studies on specific brain re-gions. Other recommended strate-gies would integrate behavioral withphysiological findings on toleranceand dependence. One importantobjective is to identify physiologicaland biochemical markers of toler-rice an' ciependence in humans.1he committee recommended the

continued use of "sophisticatedtools and techniques of neurophysi-ology and neurochemistry" for thefollowing research efforts:

define the measured neural re-sponses to ethanol and their rela-tion to human behavior (to pmthe way for testing specific hy-potheses about ethanol action onthe central nervous system [CNS])examine both acute and chroniceffects of ethanol on the CNS tthree levlssiniple neurophysio-logical systems, animals, andhuman beingsexplore the effects of ethanol enlearning, memory, and tolerancein simple system- having largeneurons or well-characterizedneural networksuse animal strains selected foralcohol-related behavior to pairhigh-response with lost esponsegroups and to study CNS activi-

186

Direct methods forstudying inheritedtendencies . . . useDNA technologies tolocate . . . specificmarkers foralcoholism.

noamine oxidase (MAO), -.4 be abiological marker that differentiatesthese subgroups of alcoholics, be-cause MAO activity is more inhib-ited by ethanol in Type 2 alcoholicsthan in Type 1 alcoholics. In addi-tion, blood platelets of alcoholicsshow lower levels of MAO activitythan do those of nonalcoholics.

Other studies use recordings ofbrain electrical activity. The electro-encephalograms (EEGs) of sons(but not daughters) of alcoholicmales are likely to show excessivehigh-frequency activity. Some re-cordings of the brain activity ofalcoholics, sons of alcoholics, andabstinent alcoholics have shownreduction in the size of a brain-wave component (P3) associatedwith thought processes involved invisual or auditory perception. Someresearchers think that these neuro-logical differences may underliedifferences in drinking behavior.

Direct methods for studying in-herited tendencies toward alcohol-related problems use DNAtechnologies to locate genes thatcan serve as specific markers foralcoholism. Data on the develop-ment of alcohol abuse and alcohol-ism across generations support thehypothesis of a t,2netic componentin familial alcoholism.

The committee made the follow-ing recomme- itions for geneticresearch:

ties related to ethanol reinforce-ment, tolerance, and withdrawaluse brain-imaging techniques andelectrophysiological tests in con-junction with neurocliemical testsof blood or urine to study indi-viduals in withdrawal, `sigh -riskindividuals prior to alcohol expo-sure, and individuals experiencingtolerance or dependence.

Heritable determinants of risk(Chapter 7). Genetics researchers areexploring specific genetic compo-nents involved in alcoholii.m alongwith the predisposing effects ofenvironmental and experientialfactors.

Researchers now have access tosophisticated computer techniquesand multivariate statistics. Throughfactor analysis, they have foundthat alcohol dependence and loss ofcontrol, social problems, personal-ity variables, family problems,affective symptoms, and psychoticsymptoms require separateassessment.

Recently, longitudinal studies offamilies have enabled researchers todistinguish antecedents of an illnessfrom sequelae of the illness.

According to one theory, alcohol-ism takes two basic fornis: milieulimited (Type 1) and male limited(Type 2). For the Type 1 subgroup,predisposing environmental factorsappear to be nec,!ssary for alcoi:ol-ism to o,velop. Another studysuggests that a CNS enzyme, mo-

9 l

seek explicit definitions of clinicalsubtypesconduct multilevel evaluations ofthe proposed subtypesconduit prospective longitudinalresearch to evaluate variablesproposed as behavioral markersfor a predisposition to Jcoholismassess clinical, neurobiologi:al,and psychosocial variationsacross two or more generations tolearn about gene-environmentinteractionsstudy alcohol responsesinitialsensitivity, tolerance, and rein-

ALCOHOL HEAUfli & RV-SEARCH WORLD

forcementin nonjuvenile sub-jects at high nsk for alcoholismuse molecular genetics, brainimaging, and noninvasive screen-ing for enzymes to study suscepti-bility in familiesconduct parallel studies involvingcell lines from well-describedmembers of susceptible families,clinical profiles of subtypes, andquantitative modeling.

Social determinants of risk(Chsp'..m 8). Social and epidemio-logical research has demonstratedthat major changes occur in drink-ing habits, both in whole popula-tions and within the course ofindividual lives. In additioA, thefocus of this research area hasbroadened to include alcohol-related beliefs, behaviors, and var-ied problems.

Within this context, the commit-tee drew attention to the need foradditional research on Americanwome 1, on the extent to whichcouples function as social units intheir chinking, on differences whenp onie drink in same -sex or mixed-sex groups, and on how individualsinfluence each other's drinking. Inaddition, drinking among the gen-eral, nonethnic population of thecountry merits more attention, andsectional differences require analy-sis. Finally, age-oriented analyses ofdrinking in the United States sug-gest that different risks are encoun-tered in different age groups. Thereis a need foi mapping out the life-time course of drinking problems.Emphasis on the incept:on of heavydrinking may now need to be bal-anced by such factors as stress or aspouse's drinking, which may ,,ts-tain heavy drinking over a period ofyears. Research on racial and ethnicdifferences in drinking recently hasbeen aided by nationwide surveysof black and Hispanic populations.Identifying variations in drinkingpatterns and problems within, aswell as between, major ethnic cate-

Vat,. 13, Na 2, 1989

gories has provided important newinsights.

Social research that addressessolving alcohol-related problemsgives considerable attention to pub-lic efforts. For example, the U.S.literature on the effects of changingthe legal drinking age and ondrinking- and driving countermea-sures is strong. in the many studieson the effects of alcohol on drivingand other performance tasks requir-ing skills and judgment, however,knowledge gaps still exist regardingsuch important matters as the ef-fects of an alcohol hangcner and thecombined effects of alcohol andfatigue.

Other countries have led the wayin studying drinking-related policyand cultural shifts. The [OM reportemphasizes th° need for interna-tional comparative studies.

Social psychology in the UnitedStates has been influenced by thepsychology of thinking. This cogni-tive emphasis has led to researchshowing that expectations aboutalcohol consumption affectdrinking-related behaviorandexplanations of such behavior. Sim-ilarly, a cognitive approach is beingused to develop strategies for recov-ery and relapse prevention. In-crewed attention to studies ofsocial and environmental correlatesof heavy drinking also is indicated.

The first IOM report called forstudies involving "natural experi-ments," such as changes in law,policy or c:rcumstances to effectsocial chai.ge. Such studies stilt areneeded. In addition. interest isgrowing for trend analyses andhistorical studies of alcohol issues

patterns. The IOM panel spe-cifically recommends th- applica-tion of qualitative historicalmethods to major issues in thecauses and correlates of a'coholproblems ''

In the area of social research,measurement issues are increasinglyimportant. Because of improve-

9'

ments in measuring blood alcohollevels, substantial progress can beexpected soon in reporting casual-ties aitd other problems related toacute effects of alcohol consump-tion. In addition, researchersshould measure more than onedimension of alcohol consumption,such as average daily consumption.No single dimension of drinkingbehavior is adequate for measuringthe risks associated with a widerange of multtfactor problems.

The committee made the follow-ing recommendations for social andepidemiological research:

conduct both qualitative andquantitative historical studies onpatterns of change and relationsuse population sii- 'ys, s*atisticalseries, and other sources to mappatterns and covariations of alco-hol use, covering the diverse sec-tions of the U.S. populationconduct longitudinal studies ofindividual drinking practices andproblems, both immediate andlong termconduct qualitative studies ofnormative and behavioral pat-terns at a given time and aschanges occur in the course of alifetimeconduct studies of natural andFanned policy experiments tolearn how policy interventionsand other social changes affectdrinking practi..es and problems.

Psychopathology related to alco-hol abuse (Chapter 9). A psychiat-ric disorder can precede, accompany,or follow alcohol abuse. The causalrelations are unclear, and this areaof alcohol resea.ch abounds withunsettles issues. Foremost amongthese are the psychop lhology defi-nitions and the psychiatric criteriafor alcohol dependence.

The committee examined a num-ber of areas, including disorders,depression, drug codependency, andwithdrawal:

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IOM Report

Antisocial personality disorder(ASP). Individuals with ASPreport dysphoric moods (anx-ious, unhappy), demonstrateimpulsive behavie, rooted insensation-seeking attitudes, andtend to have poor and unstableobject relations (associationswith other individuals, particu-larly) and a history of under-achievement despite normal orabove normal intelligence. Re-search on ASP as a risk factorfor alcoholism would be ad-vanced by longitudinal studiesdesigned to identify biolog:cal,psychosocial, environmental,behavioral, and genetic variablesrelated to childhood conductdisorder (CCD), a history ofwhich is often required for adiagnosis of ASP. Another ques-tion for future study is a possiblerelationship of CCD (with orwithout adult ASP) to alcohol-related aggressive or violent be-havior in some individuals.

Anxiety disorders. Althoughanxiety disorders are commonlyfound in association with alco-holism, very few patients appearto have had anxiety symptomsthat antedate their alcohol-related problems.

Clinical studies show that anxi-ety symptoms increase duringheavy drinking or periodicallyduring abstinence of severalweeks. Interaction between alco-hol dependence and the anxietydisorder may complicate thecourse of alcoholism and recov-ery; it thus merits further investi-gation.

Depression. CL -leal depressionappears frequently in alcoholics,predominant!y in females. Depres-sive symptoms in alcoholics prob-ably have multiple causes, rangingfrom the toxic effects of alcoholto the presence of personalitydisorders antedating the use ofalcohol. Such symptoms, oftenpresent during drinking and the

acute withdrawal period, tend toclear over time. Some alcoholics,however, report feeling depressedover months or years.

It has been reported that de-toxified alcoholics may metabo-lize some of the tricyclicantidepressants so rapidly thatthe usual therapeutic dosage maynot be optimal. Future studies inalcoholic patients should includeblood level measures.

Biological measures used instudies of depression in nonalco-holic subjects may be of limitedu;:e in studies of recently detoxi-fied alcoholics. This is p.irticu-larlv true of the dexamethasonesuppression test and studies in-voiving catecholamines, sero-tonin, or sleep variables.

Future studies of depressionand its treatment in the alcoholiccall for addressing the questionof a separately diagnosable affec-tive disorder; measuring the levelof cognitive function or impair-ment; probing for a family his-tory of affective illness, includingcareful histories of alcohol useand dependence and of depres-sive symptomatoiogy; and assess-ing life stmss and the adequacyof social supports.

Drug dependencies. The prob-lems arising from combined useof alcohol and other drugs havechanged as "drugs of choice"have changed in the general pop-ulation. Systematic data on druguse and Cependence in alcoholicpatients would clarify the preva-lence and current types of drugaependencies and potential im-pact on treatment needs. Suchdata can lead to hypotheses forsmall-scale clinical research.

Withdrawal syndrome. The acutealcohol withdrawal syndromeincludes anxiety, agitation, irrita-bility, and tremors, in addition toabnormalities in body tempera-ture, blood pressure, heart rate,and seizure threshold. After

9;

acute i. Adrawal, many patientscompiam of persistent insomr;aand feelings of depression oranxiety.

Some of these symptoms mayindicate long-lasting physiologi-cal changes, which may contrib-ute to the risk of relapse. Thedata on brain hyperexcitabilitythat persists after ces,ation ofalcohol consumption suggest thatalcohol consumption by an absti-nent alcoholic may elicitwithdrawal-like symptoms.

Research using animal modelsis recommended to dete.minewhether latent hyperexcitability(a tendency toward high excitabil-ity in the brain) is associated witha persistent tendency to consumealcohol. Careful studies involvinglong-term abstinent alcoholicswould also be of interest.

Also related to hyperexcitabil-ity is a suggested study ofethanol-induced changes in theactivity of gamma-aminobutyricacid (GABA) in the brains ofanimal models. Gt BA is theprincipal transmitter of nervesignals that inhibit activity ofother nerve cells in the brain.Other studies could assess therelationship between dependenceseverity and the electrophysiolog-ical dimensions of long-termabstinence.

The committee also made thefollowing psychiatric researchrecommendations:

conduct longitudinal studies toidentify risk-related biologicaland environmental factorscompare in various settings theresults of specific psychopathol-ogy diagnoses with assessmentsbased on more global or inclusiveobservationsexamine in various settings thedistinction bctween primary andsecondary psychopathologiesassociated with alcoholism

AL( OHM ilk ALTO & RF-SEARCH WORLD

study (in well-controlled treat-ment trials as weil as in small-scale laboi /tory investigations)the subjective symptoms associ-ated with subacute withdrawaland post-withdrawal recovery inrelation to abnormalities in brainfunction and thinking describedin alcoholic patients afterwithdrawal.

Medics; consequences of alcoholabuse (Chapter 10). The kidneysand the lungs eliminate only about2 to 10 percent of beverage alcohol,ci ethanol, absorbed by the body.The remaining ethanol may damageboth individual cells and the func-tioning of organs and other tissues.Direci cell injury by ethanol isthought to be related to its disrup-tive effects on cell membranes andon structures within the cell. Tissuedamage from ethanol is believed toresult either from biochemicalchanges that accompany the metab-olism of ethanolin effect, thebody's normal process of convert-ing ethanol to other substancesorfrom direct effects of alcohol as asolvent. However, little is knownabout the primary effects of etha-nol metabolism in most tissues.

The primary target organs foralcohol injury are the liver, pan-creas, heart, and bo:Ic mut,.Other important targets 2 .ieendocrine (hormone), gastrointesti-nal (digestive), and immune sys-tems. Epidemiological studiescharting the development of result-ing alcohol-related disorders areneeded. Other research objectivesinclude nutritional studies and thestudy of cardiovascular function,pulmonary function, hypertension,and levels of white blood cells andcirculating hormones as related tolevels of ethanol and other drugs,espe , tobacco.

The committee recommendedspecific biomedical research in awide range of areas. Several of theserecommendations are listed below.

VoL.13, Na 2, 1989

Concentrate on humans in thestudy of liver disease (in partbecause no experimental animalshave been found to develop acondition analogous to the hepa-titis fund in humans) and con-sider using magnetic resonanceimaging (MRI), a technique thatproduces x-ray-like images of softtissues, to help explain alcohol-inducca structural changes withinliver cells.For cancer-related alcohol re-search, use various approaches tostudy growth regulation, cancer-provoking enzyme changes in theliver, and tumor development inalcohol-preferring rodents.

The primary targetorgans for alcoholinjury are the liver,pancreas, heari, andbone marrow.

Conduct further research to ex-plain the apparent relationshipbetween alcohol abuse and can-cerous and precancerous condi-tions, with possible emphasis oncongeners (alcoholic 'leverageingredients other than ethanol)that may contribute to the growthof tumors.Continue to study the effects ofethanol and its metabolism on thebiology of pancreatic funet,nand on the development of tech-niques for the detection of pan-creatic injury.Examine ho.v ethanol changesgastrointestinal functions, includ-ing alterations in regulation ofthe digestive pro "ess by the endo-crine and nervous systuns, effectsof ethanol on the cells that linegastrointestinal organs, and theorigin of nutritional deficienciesand the role that these deficien-cies play in the development oftissue injury.

9

Examine nutrient deficiencies fortissue repair in the wake ofethanol-related injury and thepotential role of nutritional defi-ciencies in such medical problemsas fetal alcohol syndrome, liverdisease, pancreatic disease, andthe development of cancer.Study the mechanisms by whichethanol induces hyperglycemia,ketoacidosis, and other disordersinvolving fats and carbohydrates.For better insight into how alco-hol consumption can disruptcardiac rhythms, increase hyper-tension, damage the heart mus-cle, and decrease cell populationsin the blood (causing clinicalanemia and other blood disor-ders), concentrate on imi..tovingmethods for taking drinking his-tories, design studies to identifypredisposing genetic factors,and develop better diagnostictechniques.Look more closely at alcohol'seffects on cholesterol metabolism,with emphasis on the cholesteroltransported in the bloodstream inhigh-density lipoprotein partic.zs.Conduct additional epidemiologi-cal and prospective trials toclarify the relationship betweenalcohol use and heart disease.Collect epidemiological details onalcohol-induced brain damage,especially as associated withmemory disorders.Continue to examine the neuro-logical damage to the fetus as aresult of alcohol and the possiblerole of nutrition in brain atrophyand cognitive loss.Analyze the medical conse-quences of alcohol consumptionon th.., endocrine system, espe-cial:), as its hormonal functionsare complicated by interactionwith other variables, includingnun ition status and alcohol -it lated stress.Study in greater depth how alco-hol can cause atrophy of the go-nads, impotence, and infertility.

0 189

IOM Report

Determine the effects of chronicalcohol abuse on estrogen-responsive tissues and other targettissues in women.Investigate the effects of plant-derived estrogens in alcoholicbeverages.Conduct further work on theethanol-thyroid metabolism rela-tionship and its effect on theliver.

Study the specific effects ofchronic alcohol intake on thehypothalamic-pituitary-adrenalaxis.Determine the medical effect ofalcohol abuse on the immunesystem in five specific areas: 1)conduct epidemiological studiesto learn whether alcohol abusers

are especially susceptible to hu-man immunodeficiency virus(HIV) infection and progressivedisease. 2) study whether alcoholaffects the course of the diseasein individuals already infected byHt V, 3) study the proportionsand the interactions of T4 and T8cells in alcoholics who haveAIDS, 4) compare infectiousdiseases and tumors in alcoholicand nonalcoholic AIDS patients,and 5) assess the effects of etha-nol on the numbers and activitiesof natural killer (NK) lympho-cytes (because of the possible roleof NK cells in the immune re-sponse to tumors).Correlate data on tobacco smok-ing and alcohol drinking with

data on lung infections.kialyzc the relationship betweeninfectious lung disease and socio-economic status among alcoholabusers.Conduct epidemiological andbiomedical studies about alcohol-related birth defects.Study the complexities of drug-and-ethanol effects with eachdrug to learn about specificinteractions.Study the relationship of trau-matic injuries and alcohol in fivetypes of research: 1) conductepidemiological studies on therole of alcohol in accidents intransportation, home, work, andrecreational settings; 2) study theme -:hanisms involved in shock

6-WittAffAffoldistaioden

Ask**madal

dtudtazinter-

nem impulses to other nerves,muscles, or :lands.

Cyclic AMR A "second messen-gee" cheMical that, when trig-ger** innomhrg aerieInenageinabki the recelw

napond.:Zondr 'nit that re-State Of-grief fol-

kileiDtbk*UtiattitkRaktivedePrendost_11 toadied off by

nienthand musily lastsa short time. Endogenous de-preadost no-obeloui Wa-nd catriaand may be chronic.A depression offer kind isdint & wben acme enough tomake 'treatment.

Deem1l -lei medlar dies-

Syndrome-involving

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lethenol) to

190

Chemicalcrid by etha-

the two princi-Pal etismrot Metabolites' are,

first, acetaldehyde and, second,acetate.

Gammaarninobatyric acid(OARA). A substance that,when transmitted through nervefibers in the brain, inhibits orreduces the &kg of imptdsesby other brain nerve cells.

Hepatoma A liver tumor, eitherbenign or cancerous.

HIE Human immunodeficiencyvirus, the agent thought to beresponsible for AIDS andAIDSrelated syndrome.

Hyperilycemkt and ketoaddosits.Related clisorden that resatfrom the body's inability tometabolize carbohydrates (e.g.,sugar)°la a normal fashion.

Messenger 111+14. Ribonuckk acidstrands that any genetic "mes-sages* front the cell nucleus tothe cell plasma, where theyguide the synthesis of specificproteins.

MorNdiot Occurrence of disease,Mortalitx 0061111111101 of death.MullAva*te statistics. Any slid*.

deal technique capable of ana-lyzing the interaction of severalvariables at the same time.

ALCOHOL HEALTH & RESEARCH WORLD

from bleeding during acuteintoxication and in cases of alco-holism; 3) evaluate the patho-physiolou of the drowning,intoxicated patient, to reducefatalities from nonlethal levelsof blood alcohol; 4) study theeffects of ethanol on bone metab-olism; and 5) clarify the relation-ships of alcoholism and acuteintoxication in burn patients.

Conse pences of drinking onperformance (Chapter 11). To per-form a task, a person must coordi-nate several processessensory,perceptual, cognitive, and motor.Alcohol impairs each of these, andits use can result in traumatic in-jury. Even in healthy subjects, rela-

tively low concentrations of bloodalcohol (BAC less than 35 mg/100ml) can disturb visual perception,muscle control, eye-hand coordina-tion, and visually guided movementthrough space.

Promising areas for performanceresearch are electrophysiologicalresponses to visual stimuli, percep-tual style (that is, how oneperceives the effects of one's sur-roundings), selective attention. andapplied methods in human per-formance.

Factors other than the level ofethanol have been found to causevariations in perception and con-trol, including beverage type,expectation of an alcohol effect, adriver's apparent effort to compen-

sate for the perceived alcohol ef-fects, personality type, and,possibly, heredity.

The committee made the follow-ing recommendations for relatedresearch:

broaden the research alreadyconducted using motor vehicledriving to measure performancedeficits induced by alcohol con-sumption and begin to use so-phisticated experimental designsinvolving many human factors totest a wider spectrum c' alcoholeffectssimultaneously analyze the skillsinvolved in machine operation byhuman beings, i.e., monitoring,interpretation, and intervention.

pirativet The route taken,nerve fibers and nerve

*bring about a

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pattern:J.The patterns*fining whaz is te-

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VOL. 13. Na 2, 1989

Prevaknce and incidence. In epi-demiology, prevalence is theoverall occurrence of a behavioror a condition (e.g., the preys-le:774 of alcoholism is low insome countries). Incidence isthe documented occurrence ofthat beinvior or conditionwithin a set time period andpopulation (e.g., the incidenceof new cases of malaria in Cubawas 37 in 1970).

Psychoactive substance. Any sub-stance eat affects the mind orbehavior.

Psychopathology. The branch ofknowledge that deals with men-tal and emotional disorders.

Receptor molecules. In brain re-search, receptor molecules arethe means through which nervecells (neurons) receive "mes-ses*" 1t the form of chemicalsreleased front other nave cells.These chemical messengers areknew* as nanotmnsmitters.Receilter moleades are"Ice*" to receive specificneurotransmittes.

Recombinant DNA. Deoxyribonu-cleic acid (the genetic material

in all forms of animal life) thathas had a strip of DNA fromanother organism inserted intoits structure.

Serotonin. Or e of the substancesin the that transmits nerveimpulses.

Subacute withdrawal. Withdrawalfrom the effects of an addictivesubstance in which the symp-toms are less severe than inacute withdrawal; often occur-ring as a lengthy phase of thewithdrawal process followingthe more dramatic phase ofacute withdrawal.

Thyrotropin-releasing hormone. Asubstance that signals the pitui-tary gland to release thyrotro-pin, which then stimulatesactivity in the thyroid gland.

7Hcyclk ant:dep.-amts. A familyof drugs used to relieve depres-sion; all have three-ring molecu-lar structures.

Vasoptassia. A hormone producedin the brain that is normally anantidiuretic (inhibits urineproduction) but also may beinvolved in memory and inresponses to ethanol...

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IOM Report

Social consequences of alcoholabuse (Chapter 12). Social prob-lems associated with alcohol abuseassume a variety of forms and usu-ally involve several factors otherthan alcohol. The committee ad-dressed both individual conse-quences of drinking alcchol andbroader societal issues.

In addressing individual issues,the committee included problems athome and at work. The familylooms large as an agent for infor-mal social control of drinking anddrinking-associated behavior. Inself-reports by drinkers, familyproblems are the most frequentlyacknowledged type of alcohol-fclated problem. The literature onthe role of drunkenness in familyviolence is largely anecdotal. Thetime has come for studies that aresensitive to intimate relationships,large in scale, and comprehensive inscope.

The adult children of alcoholicsmovement has been a catalyst for abody of literature that calls for alarge research agenda. Studies inthis area can be based on positiveas well as negative outcomes forchildren, but most of the evidencepoints to adverse effects.

Despite the importance of workin human affairs, surprisingly littleresearch is being done on tne rela-tion between drinking and working.The current emphasis is on theworkplace as a case-finding institu-tion. However, the sociology ofalcohol and occupation deservesattention. Unanswered questionsinclude the contributions of theoccupations themselves, the predis-positions of people in those occu-pations, the availability of inex-pensive alcohol in certain occupa-tional environments, and the demo-graphics of employees in the high-risk occupations. In this context,the committee recommended thefollowing:

192

conduct research on alcohol as afcctor in industrial accidents andin unsound decision processes byprofessionals in the workplacestudy systematically occupation-related exposure to chemicals thatinteract with alcohol and otherpsychoactive drugs.

Among the broader societal is-sLcs, the committee considered themany casualties that involve alco-hol. Recommended are prevention-oriented analyses of the role ofalcohol in the sequence of eventsleading to a casualty, populationsurveys on the relationship betweendrinking and accidents, emergencyroom and other epidemiologicalstudies of alcohol involvement ininjurie , and case studies that control for environmental factors inalcohol-related accidents. In ease-control studies, research designsmight best seek an explanation forhow alcohol and the circumstancesof the casualty are related.

The impact of d, ankenness anddrinking history on trauma survivaland recovery also requires furtherstudy to provide guidelines tohealth care systems and profession-als. With regard to both individualand societal issues related to theconsequences of drinking, thecommittee made the followingrecommendations:

augment studies of the familyprocess and alcoholism with stud-ies exploring the role of drinkingand the resulting changes in abroad cross-section of Americarfamiliesexai.nne further the effects ofalcohol on sexual functioning andreproduction, particularly inwomenfocus on alcohol issues related torape and teenage pregnancyexamine the possibility that alco-hol may play a role in the trans-mission of HIV and the develop-ment of AIDS by facilitating i.sky

r. t/

behavior and/or by interferingwith normal immune responsesexplore systematically thealcohol-and-crime connection,including consideration of recentresearch that suggests that cul-tural, rather than pharmacologi-cal, factors link drunkenness withviolence and crimeinvestigate alcohol use as an ex-planation (i.e., an excuse) fordomestic violenceevaluate the interaction of newdrinking-and-driving regulationswith the criminal justice andtreatment systemsreexamine drinking-and-drivingbehavior with respect to the roleof alcohol in multiple-causesequencesexamine drinking-and-drivingbehavior with reference to risktaking among young menreexamine the relationship be-tween drinking and homelessnesswith reference to the rapidlychanging homt!ess poi .lation ofthe 1980scollect survey data on alcohol anddrug use, specifically about quan-tity consumed per drinkingoccasionstudy the consequences of com-bined (simultaneous or consecu-tive) use of alcohol with tobacco,sedatives, marijuana, cocaine,caffeine, and other drugs, includ-ing over-the-counter and prescrip-tion drugsinvestigate the effects on drinkingof such factors as fatigue, socialcontext, the "street" lore, andmutual enhancement (as in smok-ing and drinking)collect more epidemiological dataon both clinical and general pop-ulations for such topics as theevents leading to emergency roomepisodes involving alcohol andother drug use and combineddrug use and its consequences inhigh-usage groups.

-TIIE EDITORS

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