Substance abuse treatment as part of a total system of community response
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Research
Harold D. Holder
report
Substance abuse treatment ABSTRACT
as part of a total system of
H. Holder: Substance abuse treatment
as part of a total system of community
community response response
Treatment of substance abuse in many
communities throughout the world
is often separated from other social
and health responses to alcohol and
other drug harms. Current responses
Introduction exist like silos within the community.
Existing approaches to substance use and In addition, there are population-level
abuse in most countries have generated a policy approaches concerning the
complex but not always complimentary set distribution and sales of alcohol and
of separate programs and approaches in com- the restrictions on and enforcement
munities, normally labeled as treatment or of illegal drugs which also exist only
prevention. Treatment of substance abuse is loosely connected to treatment (or
often separated from other social and health prevention for that matter). A systems
responses to alcohol and other drug harms. approach to substance abuse and
Current government programs can exist like related problems is described in
silos or separate closed systems such that even which evaluation addresses both
within the recovery/treatment organizations clinical patient needs as well as
there are many alternative approaches, pro- overall performance demonstration.
grams, and policies which often compete for Effectiveness can be measured both
government funding and public support. This by population level reductions in use
observation is based on a number of reviews and associated problems, a second
of treatment systems. See Rist et al. (2005) for level of accountability, i.e., documented
a review of new developments in alcoholism reductions in problems of at risk groups
treatment patterns in Europe which illustrates or clients whose drinking or drug use
patterns place them at risk for future
Acknowledgment problems, and a third level of response
Presented at “Models, implications and mean- for individuals with clearly identified
ings of alcohol and drug treatment systems” (a substance-related problems, which
thematic meeting of the Kettil Bruun Society for requires intervention at the person
Social and Epidemiological Research on Alcohol) level (typically called treatment). Thus
Stockholm, Sweden on 7–9 October 2009.
within such a comprehensive system,
Submitted 29.04.2010 treatment and prevention would lose
Initial review completed 20.05.2010 their separate identities and would be
Final version accepted 09.11.2010 employed according to local needs and
NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 27. 2010 . 6 549Substance abuse treatment as part
of a total system of community response
the potential to achieve some of these points.
desired effects where the Currently in most countries, there are many agencies, min-
overall system is required istries, and organizations providing services and programs
to select the mix of related to substance abuse. The cross-national review of al-
strategies which maximizes coholism and drug abuse treatment services in Europe and
effectiveness at each level. other countries by Klingemann et al. (1992) and Klingemann
and Hunt (1998) as well as organizational analyses complet-
■ Key words ed by Durkin (2002) find that substance abuse programs are
substance abuse treatment not typically organized to provide either systematic clini-
system, prevention, cal evaluation nor performance evaluation overall. Further
evolution model, population Warner (2008) finds that very few of existing substance
-level effects abuse treatment services are providing overall health screen-
ing and thus are not evaluating their programs in terms of
effects on either total population or at risk sub-populations.
Similarly local prevention efforts operate separately from
one another, compete for funding among themselves as well
as exist largely independent of treatment with the same com-
munity. For example, simply having law enforcement (or the
judicial system) identify and mandate treatment services for
convicted persons is not the same as operating and evaluat-
ing treatment within a total system. As Holder et al. (2005)
have documented, prevention programs for substance abuse
may be co-located within the same organization for treat-
ment. Due to this diversity prevention efforts may not typi-
cally operate as though part of a common system.
In addition, there are population-level policy approach-
es concerning the distribution and sales of alcohol and the
restrictions on and enforcement of illegal drugs which also
exist only loosely connected to treatment (or prevention
programs for that matter). This is especially in the Nordic
countries, specifically Finland, Norway, Sweden, and Ice-
land, which have a long tradition of using public policy as a
means to reduce substance abuse harm. See reviews of these
policies and their history in Holder et al. (1998) and Trolldal
et al. (2000).
Over time approaches to substance abuse have been ei-
ther person-specific interventions in reducing substance
abuse by individuals (this is typically the domain of treat-
ment) and purposeful efforts to reduce subgroup or popu-
lation-level substance abuse and/or associated problems by
education or environmental/policy interventions (typically
the domain of prevention). There is clear evidence of harm
550 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 27. 2010 . 6Substance abuse treatment as part
of a total system of community response
reduction strategies for substance abuse such services and programs or policies be
(Ritter & Cameron 2006) which may or modified to take advantage of best scientif-
may not be utilized in practice. Wells et ic evidence of potential impact. For exam-
al. (2006) provide insights as to why sub- ple, Fuller et al. (2007) in a review of ex-
stance abuse treatment programs do not isting substance abuse treatment programs
operate or link with prevention efforts find a significant gap between evidence-
(even with demonstrated effectiveness). based practice (EBP) innovations and their
These authors find the lack of funding in- adoption. Further they identify 6 elements
centives for actually operating prevention which are critical to the adoption and
initiatives and the lack of accountabil- maintenance of evidence-based practices
ity for overall effects on substance abuse in their programs including program eval-
problems as key factors. This is echoed by uation for individual care as well as over-
Merrill et al. (2006) which when looking all documentation of performance which
at a large national school-based preven- can be used as feedback to staff to improve
tion effort find that the program is not or- overall performance.
ganized to select evidence-based strategies As discussed in Babor et al. (2010), the
nor to document overall effectiveness as provision of treatment is part of a compre-
a part of policy requirements. Further see hensive approach to alcohol-related prob-
discussions in Lisansky-Gomberg (2003), lems and in terms of the reduction of hu-
Brienza and Stein (2002), Tonigan (2003), man suffering, and treatment can be con-
and Babor et al. (2010) concerning treat- sidered as a form of prevention. Further,
ment services and prevention approaches Babor et al. (2010) concludes that when
as well as Holder (1998a) concerning treat- provided in response to early risky drink-
ment cost-effectiveness. ing to reduce further alcohol problems, it
Over the past 25 to 30 years, a substan- is called secondary prevention and when
tial body of scientific data and literature implemented to reduce the further damage
on the epidemiological, etiology, treatment of heavy, dependent drinking, when it is
and prevention of substance abuse has ac- initiated to control the damage associated
cumulated. From these data a better under- with chronic drinking, it is called terti-
standing of the factors that either enhance ary prevention. Anderson and Baumberg
or diminish the incidence, prevalence, (2006) have concluded that while preven-
and consequences of substance problems tion policies have been proven to be ef-
has emerged. What is missing is not sci- fective in lowering alcohol problems and
entific information on which to base effec- harm at the population level, there is lim-
tive treatment and prevention responses to ited evidence of the efficacy of individual
substance abuse. What is missing is an ap- interventions reducing population-level
proach to stimulate evaluation of effects of alcohol problems alone. Both Anderson
specific interventions or overall effective- and Baumberg (2006) and Babor et al.
ness or a group of interventions in terms of (2010) propose a mix of treatment, preven-
population level effects. In most instances, tion and policy interventions in a compre-
there is little or no consistent documenta- hensive approach to reducing harm. This
tion of effectiveness nor requirement that is also reflected by Humphreys et al. (1997)
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 551Substance abuse treatment as part
of a total system of community response
who discuss the limitations of current be an organizing frame work with the re-
evaluation approaches in government- quirement to utilize existing scientific
sponsored substance abuse treatment and evidence to identify practices and inter-
describe approaches to evaluation which ventions most likely to make the system
can both support clinical needs (effects effective and to make evaluation a natural
for individual patients) and which can be part. This is not a description of “ideals”
relevant to public policy (see also Moos & or even a replacement of current treatment
Finney 1983; McClellan et al. 2000). and prevention approaches in practice.
The goal of this paper is to present a Rather this approach identifies key func-
systems approach to substance abuse tions which can support both an evalua-
treatment and prevention in which the tion of effectiveness and enable the system
documented reduction of abuse and re- to improve over time and which could be
lated harms both at the individual patient applied to existing programs and interven-
level as well as overall effectiveness are tions. For example, a systems approach to
essential in system design. A systems ap- public education can identify the essential
proach to evaluation is about establishing functions necessary to effective education
a means to evaluate both individual and including necessary funding to support
population-level effects, and integrating activities, alternative educational delivery
evaluation as a part of natural operations. structures, measurement of student learn-
Complex systems are designed to achieve ing and improvement, and overall man-
specific outcomes. Three essential levels agement processes. However, the specific
of evaluation for this system are proposed. shape and location of schools, content of
Also one example of such an actual system classroom teaching, certification of teach-
which uses all three levels as described ers, and testing of students are to be devel-
and currently exists (in one form or an- oped specific to the goals and objectives of
other) in every developed country. Further the system and the community or culture
key steps to develop such a systems ap- in which it exists, i.e., seeking alternative
proach are given as well as illustrations of operational approaches to achieve system
logic models for drinking and driving and functions.
methamphetamine treatment and preven- Are there elements of this systems ap-
tion which provide alternative examples. proach to substance abuse already exist-
Thus this paper describes how evaluation ing? As Lisansky-Gomberg (2003), Brienza
of outcomes can be inherent such that the and Stein (2002), Tonigan (2003), Babor et
system seeks to improve over time, i.e., al. (2010), Rist et al. (2005), Humphreys
adaptation based upon success or failure. et al. (1997) and many others have de-
(See Costello 1975) scribed many essential ingredients of suc-
cessful treatment and prevention exist in
A systems approach practice and there have been a number of
for reducing substance use studies which both assess existing serv-
and abuse ices and suggest appropriate alternatives
A systems approach to reducing substance to improvement as cited above. Thus this
use and abuse problems is proposed to paper is not proposing totally new ideas
552 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
(or ideals) which have not been consid- the second level is a type of “early inter-
ered previously. What may be considered vention” component for the system and
as unique in this paper is an emphasis on might include brief intervention deliv-
population-level as well as individual- ered via existing general medical or health
level evaluation of effectiveness and an services (see Wutzke et al. 2001; Babor &
expectation that services, programs, ap- Higgens-Biddle 2000) or targeted educa-
proaches, and policies will be designed tional or support programs, e.g., as might
and implemented utilizing the best avail- be delivered for disadvantaged children,
able scientific evidence, and that the or youth, or families with risk profiles
specific goals of such a system would be (Lisansky-Gomberg 2003). In practice,
clearly defined and management held ac- interventions at this level (depending
countable. upon the population being served) could
mix smoking prevention with moderate
Standards for performance drinking interventions or diet education
evaluation within a systems to reduce obesity with heavy drinking
approach prevention. Interventions here could also
Evaluation of effectiveness is proposed to counsel persons whose drinking and/or
occur with three general levels of account- drug use patterns puts them at risk for
ability as illustrated in Figure 1. Thus the future problems. The point here is not to
first level of accountability is the reduc- specify specific types of interventions but
tion of specific substance abuse problems rather to provide incentives to support
for the entire community (this has been system management to seek the most cost
described by Holder 1998b; 2001). A sec- effective mix of services for this level, ac-
ond level of accountability would be re- counting for the characteristics and needs
ductions in problems in subgroups whose of the population being served.
members have clearly identified social or A third level for the system is a reme-
health problems or have risk for future dial response to the identified current
substance related problems. In this way, problems of individuals who are clearly
1
Universal or Community Wide Approaches
Strategies which target the entire community
Example: Drinking and driving detterence
2
indicated or identified approaches
Strategies which target subgroups with “risk” profiles
Example: First DUI Offenders
3
targeted approaches (treatment)
Strategies which work with individuals with identified problems
Example: Multiple DUI offenders
Figure 1. Levels of evaluation in a systems approach to substance abuse
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 553Substance abuse treatment as part
of a total system of community response
manifesting substance abuse problems. planned way, i.e., general strategies backed
Thus these clients are engaged in treat- up by subgroup-specific strategies which
ment approaches or modalities which are further backed up by individual strate-
have demonstrated effectiveness, i.e., gies. This occurs in public safety efforts to
are evidence-based, to reduce individu- reduce drink driving. See Figure 1. At the
al substance abuse problems. There are first level, population level countermeas-
many possible treatment and recovery ures for drink and driving are designed to
approaches which the system might uti- reduce overall incidents of driving after
lize based on best scientific evidence, de- and during drinking. Such countermeas-
pending upon the potential or actual ef- ures have been shown to have effects in
fects realized in reduced problems within reducing traffic crashes at the population
the client population. For example, see level, including the use of random breath
Raistrick et al. (2006). testing, lower limits for legal blood alco-
While these three levels roughly corre- hol concentration (BAC), suspension of
spond to the public health model of pri- driving licenses, and routine enforcement
mary, secondary, or tertiary prevention, (Babor et al. 2010). Individual drivers do
such a comprehensive system treatment come to the attention of the police as a re-
and prevention would be employed ac- sult of routine surveillance (enforcement)
cording to local needs and the potential to but also as a result of breath testing in con-
achieve overall desired effects, i.e., reduce junction with a traffic crash. Most arrested
population-level substance abuse prob- drinking drivers are “first time offenders”
lems. Thus a type of “backup” would be who have not previously been arrested for
created in which the failures of more gen- drinking and driving or have not had a
eral or universal strategies (people who traffic crash related to drinking. These first
fall out, drop out or resist, or have unique time offenders rarely repeat or are rear-
individual needs) could be served via rested as the original arrest and sanctions
more customized strategies. In this case, are sufficient to reduce future problems,
reducing existing barriers to recovery or i.e., a general intervention program assess-
increase the demand for recovery serv- ment appears to be sufficient in reducing
ices would be essential. For example, if a recidivism in this population of risky driv-
community had a large number of female ers. This is an example of a second level
drug dependent users for whom existing system response.
services were not effective, then a specif- A highly significant group within the
ic service intervention which accounted drink driving population is multiple of-
for gender and social background factors fenders who are arrested several times,
might be necessary. continue to drink and drive, and come to
the attention of the police (largely because
One example of an existing of their overall exposure to detection and
system which utilizes all three the many driving trips while impaired).
performance standards Individually they have a much higher risk
Such a system for reducing substance for traffic crashes. This subgroup clearly
abuse problems actually exists in an un- requires a specific mix of incarceration
554 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
and other sanctions and rehabilitation as which is not a substitute for percentage of
they are often less affected by more gener- underage persons who actually drink over
al population strategies to prevent drink- the past 30 days. Similarly, the monthly
ing and driving or by the second level of number of alcohol-dependent clients en-
remediation. Thus, this local set of re- rolled in services is not the same as per-
sponses to alcohol-involved traffic crashes centage of clients who are actually absti-
provides a simple example of the concept nent after 30 or 90 days.
of how general universal prevention can Step 2: Identify key intermediate or
be used to affect most of the population at intervening (causal) variables: These are
risk (general driving population) backed the variables or factors that have been
up by programs/strategies to reduce future empirically shown to affect the selected
risk of alcohol-involved traffic crashes. outcome(s) and moderating variables that
are known to enhance or diminish the
How could such a relationship of the intervening variables
comprehensive system be with outcomes. Three types of scientific
designed? research can be identified in supporting
In order to plan and design such a system, a scientifically informed system: Descrip-
the following, suggested steps are pro- tive and observational research illustrates
posed: that a particular variable(s) is generally re-
Step 1: Identify alcohol or other lated to the use of a particular substance
drug-related outcomes which are to be or associated problem. Associative or re-
achieved: Outcomes for the system can be lational research examines the association
proximal, intermediate, or distal outcomes of one or more specific variables with sub-
(i.e., final outcome of interest). Interven- stance abuse and/or associated problems,
tion or longitudinal research determines i.e., this variable appears often with a spe-
whether substance abuse and/or associ- cific problem or similar problems. Such
ated problems change as a result of alter- variables are documented in Holder et al.
ing (either through intended change by (2005) along with a summary of scientific
planned prevention or unplanned natural/ empirical evidence.
unintentional change) specific outcomes, Step 3: Develop a logic model: A logic
either at the individual person level, at the model is a display of a sequence of steps
small targeted group level, or at the popu- that describes the conceptual framework
lation level. Outcomes could be identi- used to define and address a problem
fied at many points in a system plan, here through implementing programs, prac-
outcome primarily refers to distal or final tices, or policies. (see Rogers 2005; Weiss
outcome(s) for which the system is ac- 1972). A Logic Model is not an ideal, i.e.,
countable. Outcomes should be measured this is the only way for a system to be de-
in terms of changes in behaviors or events signed. Rather a logic model can be an es-
of interest. For example, changes in at- sential evaluation tool to display the best
titudes toward serving alcohol to minors available scientific evidence about key
are not a substitute for actual changes in variables and their relationships neces-
behaviors related to not serving minors sary to be effective at the client level and
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 555Substance abuse treatment as part
of a total system of community response
population level for a specific substance cluded). For example, evidence that the
abuse problem. (Conrad & Randolph 1999; drug availability (ease of access of alcohol
Millar et al. 2001; Rossi et al. 2004) and tobacco increases use) could provide
While there are many forms of logic empirical support that ease of access to il-
models, the logic model recommended licit drugs is a key variable. See documen-
here includes a specification of 1) the tation by Holder and Treno (2005).
system goal or goals to be achieved, i.e., If there is no direct empirical evidence
specific alcohol and/or drug related be- of the intermediate variable to substance
havior or events which is (are) to be re- abuse problem, the relationship could be
duced or changed (as shown in Step One presented in theoretical terms—that is,
above), 2) the intermediate (sometimes reasoned argument, based upon other re-
called “causal”) variables which need to search evidence from such variables in
be changed (or considered) in order to other conditions that can be generalized to
achieve the system goal, and 3), the inter- the case or situation. In addition, the rela-
vention components or activities designed tionship of each intermediate variable to
to change key or targeted intermediate any other key intermediate other variable
variable(s). Thus a logic model is expected is also shown and the research evidence
to specify the causal linkages among key presented, for example,
intermediate variables, and between inter-
mediate variables and intervention com- Low alcohol prices › high risk drinking ›
ponents that can affect these intermediate alcohol relation harms
variables, and the linkages between all of
these and the desired changes in alcohol Motivational interviewing › abstinence ›
and drug outcomes. See Birckmayer et al. reduced medical care
(2004) for documentation of key variables
in substance abuse which are used in the Step 4: Select the specific variables which
examples below. are to be targeted for intervention: This
The relationship of any intermediate identifies key variables which are (or there
variable to the outcome and to other vari- is empirical evidence of a potential) to be
ables should be based upon the research changed through purposeful intervention.
evidence of the relationship of the inter- Rarely does a treatment or prevention in-
mediate variable to the specific substance tervention simply reduce an outcome di-
abuse problem being addressed by the rectly, i.e., a key intermediate variable or a
system. In some cases, direct empirical cluster must be affected in order for a com-
evidence of the relationship of the inter- munity level or individual level problem
mediate variable to another variable may to be reduced. Because few intermediate
not exist as shown in the causal model. variables are easy to change, typically mul-
In these situations, the relationship is tiple components or activities are needed.
presented in theoretical terms—that is, However, more important than the number
reasoned argument, based upon other re- of components or activities is the efficacy
search evidence that can be generalized or demonstrated potential to be effective
to the situation (research citations are in- of each component or activity. That is, one
556 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
very effective prevention intervention or lidity”. This is where planners and man-
activity may be more important than sever- agers must incorporate the evidence into
al relatively ineffective activities. Further their planning with appropriate caution
by directly measuring changes in key vari- and judgment about relevance to the local
ables, it is possible to document (evaluate) situation and be prepared to modify the
whether the strategies being implemented design based upon real world experience.
are actually having an effect on targeted See discussion of treatment evaluation
variable(s). challenges by Moos and Finney (1983).
Step 5: Select the strategies, treatment Step 6: Design of overall system utiliz-
modalities, policies or programs which ing the logic model: Creating interventions
the system will undertake: This selection at all three levels for the system requires
must be based upon the research evidence identifying possible interventions and
that has been shown capable of affect- then selecting the particular intervention
ing this intermediate variable. In review- components or activities that have suffi-
ing research articles, one must ask” What cient strength to improve each or key se-
are some of the elements of credible evi- lected intermediate variable(s) at the indi-
dence?” Some strategies are stronger than vidual, small group, or community level.
others and a combination of strategies to Which interventions (policies, programs,
measure the same variable using differ- or program activities) have the greatest
ent sources adds to the strength of the demonstrated impact upon each of the se-
evidence. For example, self-report on be- lected intermediate variables? Is there suf-
havior is often the most commonly used ficient evidence that these interventions
measurement strategy, but for sensitive (policies, programs, or program activities)
data, such as drug and alcohol abuse, self- are sufficiently powerful that they will
report may not provide very accurate data. actually markedly change each selected
Thus, adding another source of data such intermediate variable and what is the evi-
as archival data on DUI arrests or emer- dence for this conclusion?
gency room visits or collecting data from There are situations when no studies are
others such as from a spouse or life part- available that evaluate a specific interven-
ner, a teacher or friend can increase confi- tion, or effects of an intervention on the
dence that the data are accurate especially targeted substance or population, i.e., no
if the data are comparable. Note that most direct scientific evidence of effects. In this
published studies of effectiveness of treat- situation, system planners may still desire
ment or prevention under scientifically a specific intervention as part of a compre-
controlled conditions emphasize “internal hensive approach to system programming.
validity,” that is, the degree to which the What are some reasonable arguments that
intervention could cause the changes de- can be made for such a selection? Such el-
sired in the outcomes measured. They do ements as these are important to include:
not typically address with such systematic • The proposed intervention is based
rigor the degree to which the results are upon a similar theory, content and struc-
generalizable to other populations, set- ture to other interventions that have em-
tings, or circumstances, i.e., “external va- pirical evidence of effectiveness. For
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 557Substance abuse treatment as part
of a total system of community response
example, evidence of limiting access to turally feasible, given the values and social
tobacco products as a means to reduce and cultural context of the community, are
youth smoking could be used to support they politically feasible given the existing
a strategy to limit youth access to drugs, power structure, are they administratively
even though there is little evidence of feasible, given the existing structure of
specific effects from controlled research relevant organizations, are they techni-
on a specific illegal drug which may be cally feasible, given the staff capabilities
targeted. and program resources, and are they fi-
• The proposed intervention has been nancially feasible, given reasonable esti-
used by a community through multiple mates of costs and likely fiscal resources?
iterations and data have been collected For these reasons, consultation with local
indicating it is effective, though not us- practitioners and residents in the process
ing a specific controlled research design. of translating the research to their culture
• The intervention is based on published and context is an essential part of good
principles of prevention and treatment systems planning.
and discussion of the intervention de- The empirically confirmed relationships
scription clearly incorporates these of intermediate variables to the distal out-
principles come support the use of specific interven-
tions. For example, Responsible Beverage
It is essential that local knowledge of cul- Service (RBS) as an intervention to reduce
ture, context, and politics be considered as overserving of alcohol at bars, restaurants,
a part of the system planning process. The or pubs has been demonstrated to decrease
advice of local practitioners who know the service to intoxicated patrons and under-
community, population segments, and lo- age persons, reduce the number of intoxi-
cal history of experience with such inter- cated patrons leaving bars, and decrease
ventions are critical in order to combine the number of car crashes (See empirical
and adapt the proposed interventions into evidence of such effects in Babor et al.
a coordinated system. Thus, what is the 2010; Treno 2003). In addition, in keeping
feasibility of proposed system policies, with a comprehensive systems approach
programs and practices, i.e., are they cul- to reducing such outcomes, the logic mod-
Examples of logic models
We have few examples in practice of this proposed system approach to substance abuse treatment and
prevention. However, it is possible to propose, for illustration only of the concepts of this paper, some
examples of logic models. There are many possible models which could be explored or proposed. Thus
these examples are not given as “ideals” but as simple illustrations. Figure 2 shows an example of logic
model for reducing alcohol-involved motor vehicle crashes related to the key intermediate variables as
specified. Based upon the empirical research, the key intermediate variables which impact drinking driv-
ing and related harm are shown. See Babor et al. (2010), Voas et al. (2008), and Horwood and Fergus-
son (2000) for empirical background for selection of key variables in this model as well as Birckmayer et
al. (2004).
558 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
Alcohol sales & service DUI enforcement
enforcement & sanctions
Retail & economic
availability (outlet
density, hours, days Multiple
Alcohol serving and First offencer drink offender
of sale discount driving interventions
pricingand taxes) sales practices drink driving
treatmen
programs
Drinking Perceived risk Driving after drinking Alcohol-related
of DUI arrest motor vehicle crashes
Community norms – Alcohol promotion Comprehensive
drinking Individual, family (adversiting, system for reduction
Drinking context and peer factors sponsorship of of alcohol-involved
(atmosphere designed commuity motor vehicle
to minimize contrlos on events) crashes
behavior)
Figure 2. Logic model for a comprehensive system to reduce alcohol-involved motor vehicle
crashes.
el provides for an intervention with first ies on these variables specifically address-
drink driving offenders (person arrested ing methamphetamine. See Birckmayer
for drink driving for the first time) in order et al. (2008) for documentation including
to reduce future drink driving events by empirical and theoretical rationale for this
this subgroup as well as a set of strategies logic model. Also see documentation of
to address the specific population of per- key variables for this logic model in John-
sons who are arrested for multiple drink son et al. (2007) and Miller et al. (2009).
driving offenses.
Figure 3 illustrates a simple alterna- Summary and conclusions
tive logic model for illicit drug use, e.g., The systems approach proposed here is
a systems response to methamphetamine to identify elements or functions within
including interdiction to reduce supply an actual system in which evaluation of
and availability and a recovery (detoxi- treatment and prevention efforts can oc-
fication and treatment) response to indi- cur. Further, these functions can be used
vidual dependency. In this example, the to stimulate accountability for reducing
logic model is derived from the empirical substance abuse problems and harm and
evidence of similar intermediate variables to support the increased use of evidence-
from other drugs, other than methamphet- based practices and policies. The effec-
amine as the research evidence concern- tiveness of this system is to be measured
ing key variables in this logic model is both by population level reductions in use
limited and there are few published stud- and associated alcohol and drug problems,
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 559Substance abuse treatment as part
of a total system of community response
Community
concern about
Meth beliefs
Community norms meth harm
– attitudes
(enforcement & use) – perceived social norms
Enforcement
– expectancies
Meth
production Price Meth
Laws Meth associated
(production use problems
supplies, sale, Perceived risk
& possesion) of arrest
(production, sale Supply available
or possession) for purchase Detox and
treatment for
meth
dependency
Figure 3. Metamphetamine logic model
a second level of accountability or evalu- examples above. Some of the elements
ation, i.e., documented reductions in the may be shared in common and many may
problems of subgroups who have risk pro- be unique. Thus what makes a system is
files, and recovery or relapse of individual the intentional design to address specific
clients with clearly identified individual goals and to integrate all necessary ele-
drinking and/or drug use problems. ments for goal achievement. The trust of
The proposed design is such that the this paper is to extend beyond organiza-
system evolves and adapts as it builds cu- tional boundaries and to seek ways to inte-
mulative evidence of what works and why grate across system elements. Perhaps the
it works and which kinds of interventions response to drink driving is a good exam-
have the greatest impact. As research pro- ple of a quasi-functioning system (though
vides more information about what kinds it could certainly be improved) which ex-
of strategies affect specific intermediate ists across several organizations in most
variables, the logic models can utilize in- communities or countries.
creasingly effective actions. For such a comprehensive, self-adapting
In this paper, a system is not necessarily system to be created in practice would
a single organizational entity but rather an not require existing treatment and pre-
integrated and interacting set of interven- vention organizations and agencies to be
tions, programs and policies which work abandoned. Rather the key functions pre-
together over time to achieve specific sented in this paper, if put into practice,
goals. Thus within a single or across mul- would stimulate improved evaluation of
tiple organizations, there may be several effectiveness at the individual, risk group,
functioning systems, each with its own and population levels. If evaluation of
unique collection of elements and per- effectiveness becomes an essential func-
formance standards as illustrated in the tion, then low or non effective approaches
560 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
would need to be replaced with evidence- both accountability and support of routine
based approaches which increase effec- evaluation, the viability of the proposed sys-
tiveness. tems approach is limited.
Why has existing organizations or agen- However, this does not mean that estab-
cies which provide treatment and evalu- lishing operating systems, in which eval-
ation, not incorporated these functions? uation of effects can not be created or is
Some of the complex answers to this ques- technically infeasible. Perhaps the greatest
tion are addressed in the introduction to this limiting factor is the will of government
paper which reviews a number of assess- ministries and municipal agencies to actu-
ments of contemporary treatment and pre- ally require this level of evaluation and ac-
vention and the role of evaluation. Perhaps, countability of substance abuse treatment
in a simplistic answer, governments do not and prevention in practice.
require treatment or prevention efforts to be
Harold D. Holder, researcher
evaluated in practice and thus there is lim-
Prevention Research Center
ited accountability. Further, in a time of con- Pacific Institute for Research and Evaluation
siderable unstable economic conditions, the Berkeley, California, USA
cost and resources to support evaluation are E-mail: holder@PREV.org
simply not provided. As a result, without
REFERENCES
Anderson, P. & Baumberg, B. (2006): Alcohol Birckmayer, J. & Fisher, D.A. & Holder, H.D.
in Europe: a public health perspective. & Yacoubian, G. S. (2008): Prevention of
London: Institute of Alcohol Studies Methamphetamine Abuse: Can Existing
Babor, T.F. & Higgins-Biddle, J.C. (2000): Evidence Inform Community Prevention?
Alcohol Screening and Brief Interven- Journal of Drug Education 38 (2): 165–183
tion: Dissemination Strategies for Medical Birckmayer, J. & Holder, H.D. & Yacoubian, G.
Practice and Public Health. Addiction 95 S. & Friend, K. B. (2004): A General Causal
(5): 677–686 Model to Guide Alcohol, Tobacco, and Illic-
Babor, T.& Caetano, R. & Casswell, S. & Ed- it Drug Prevention: Assessing the Research
wards, G. & Giesbrecht, N. & Graham, K. & Evidence. Journal of Drug Education 34 (2):
Grube, J. & Hill, L. & Holder, H. & Homel, 121–153
R. & Livingston, M. & Österberg, E. & Rehm, Conrad, K. J. & Randolph, F. L. (1999): Creating
J. & Room, R. & Rossow, I. (2010): Alcohol: and using logic models: Four perspectives.
No Ordinary Commodity: Research and Alcoholism Treatment Quarterly 17 (1–2):
Public Policy. Second Edition, Substantial- 17–32
ly Revised. New York: Oxford University Costello, R. M. (1975): Alcoholism Treatment
Press and Evaluation: In Search of Methods. Sub-
Brienza, R. S. & Stein, M. D. (2002): Alcohol stance Use and Misuse 10 (2): 251–275
use disorders in primary care: Do gender- Durkin, E.M. (2002): An Organizational Analy-
specific differences exist? Journal of Gen- sis of Psychosocial and Medical Services in
eral Internal Medicine 17 (5): 387–397 Outpatient Drug Abuse Treatment Pro-
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 561Substance abuse treatment as part
of a total system of community response
grams. The Social Service Review 76 (3): abuse treatment system. The Journal of
406–429 Behavioral Health Services and Research
Fuller, B. E. & Rieckmann, T. & Nunes, E. V. 24 (4): 373–385
& Miller, M. & Arfken, C. & Edmundson, Johnson, K. & Holder, H. & Ogilvie, K. & Col-
E. & McCarty, D. (2007): Organizational lins, D. & Courser, M. & Miller, B. & Moore,
readiness for change and opinions toward R. & Saltz, B. & Ogilvie, D. & Saylor, B.
treatment innovations. Journal of Substance (2007): A Community Prevention Model to
Abuse Treatment 33 (2): 183–192 Reduce Youth from Inhaling and Ingesting
Holder, H.D. (2001): Prevention of alcohol Harmful Legal Products. Journal of Drug
problems in the 21st century: Challenges Education 37: 227–47
and opportunities, The American Journal Klingemann,H. & Takala, J.-P. & Hunt, G.
on Addictions (10): 1–15 (1992): Cure, care, or control: alcoholism
Holder, H.D. (1998a): The cost offsets of treatment in sixteen countries. Albany, NY:
alcoholism treatment. In: Galanter, M. (ed.): State University of New York Press
Recent Developments in Alcoholism. The Klingemann, H. & Hunt, G. (eds.)(1998): Drug
Consequences of Alcoholism 14: 361–374. treatment systems in an international per-
New York: Plenum Publishing Corporation spective: drugs, demons, and delinquents.
Holder, H.D. (1998b): Alcohol and the Com- Thousand Oaks, Calif.: Sage
munity: A Systems Approach to Preven- Lisansky-Gomberg, E. S. (2003): Treatment for
tion. Cambridge: Cambridge University alcohol-related problems: Special popula-
Press tions. Research opportunities. In: Galanter,
Holder, H.D. & Treno, A. & Levy, D. (2005): M. (ed.): Recent developments in alcohol-
Community systems and ecologies of drug ism 16: 313–333. New York, NY: Kluwer
and alcohol problems. In: Stockwell, T. & Academic/Plenum Publishers
Gruenewald, P. & Toumbourou, J. & Loxley, McLellan, T. & Lewis, D. & O’Brien, C.P. &
W. (eds.) Preventing Harmful Substance Kleber, H.D. (2000): Drug Dependence.
Use: The Evidence Base for Policy and A Chronic Medical Illness: Implications
Practice. Chichester, West Sussex, England: for Treatment, Insurance, and Outcomes
John Wiley & Sons, Ltd Evaluation. Journal of American Medicine
Holder, H.D. & Treno, A.J. (2005): Mov- Association 284 (13): 1693
ing toward a common evidence base for Merrill, J.C. & Pinsky, I. & Killeya-Jones, L. &
alcohol and other drug prevention policy. Sloboda, Z. & Dilascio, T. (2006): Substance
In: Stockwell, T. & Gruenewald, P. Toum- abuse prevention infrastructure: a survey-
bourou, J. & Loxley, W. (eds.): Preventing based study of the organizational structure
Harmful Substance Use: The Evidence Base and function of the D.A.R.E. program.
for Policy and Practice. Chichester, West Substance Abuse Treatment, Prevention
Sussex, England: John Wiley & Sons, Ltd and Policy 1:25
Holder, H.D. & Kühlhorn, E. & Nordlund, S. & Millar, A. & Simeone, R.S. & Carnevale, J.T.
Österberg, E. & Romelsjö, A. & Ugland, T. (2001): Logic models: a systems tool for
(1998): European Integration and Nordic performance management. Evaluation and
Alcohol Policies: Changes in Alcohol Con- Program Planning 24: 73–81
trols and Consequences in Finland, Norway Miller, B.A. & Holder, H.D. & Voas, R.B. (2009):
and Sweden, 1980–1997. Brookfield, VT: Environmental strategies for prevention
Ashgate Publishing Company of drug use and risks in clubs. Journal of
Horwood, L.J. & Fergusson, D.M. (2000): Drink Substance Use, 14 (1): 19–38
driving and traffic accidents in young Moos, R.H. & Finney, J.W. (1983): The ex-
people. Accident Analysis & Prevention 32 panding scope of alcoholism treatment
(6): 805–814 evaluation. American Psychologist 38 (10):
Humphreys, K. & Hamilton, E.G & Moos, R.H. 1036–1044
& Suchinsky, R.T. (1997): Policy-relevant Raistrick, D, & Heather, N. & Godfrey, C.
program evaluation in a national substance (2006): Review of the effectiveness of
562 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 2 7. 2 0 1 0 . 6Substance abuse treatment as part
of a total system of community response
treatment for alcohol problems. London: Holder, H.D. (ed.): Sweden and the Euro-
National Treatment Agency for Substance pean Union: Changes in National Alcohol
Misuse Policy and Their Consequences, Stock-
Rist, F. & Randall, C.L. & Heather, N. & Mann, holm: Almqvist & Wiksell International
K. (2005): New Developments in Alco- Voas, R. B. & Fisher, D. A. & Tippetts, A. S.;
holism Treatment Research in Europe, & Fell, J. C. & Blackman, K. (2008): The
Alcoholism: Clinical and Experimental relationship of underage drinking laws
Research 29:1127–1132 to reductions in drinking drivers in fatal
Ritter, A. & Cameron, J. (2006): A review of the crashes in the United States. Accident;
efficacy and effectiveness of harm reduc- Analysis and Prevention 40: 1430–1440
tion strategies for alcohol, tobacco and Lynn A. W. (2008): An Analysis of the Capac-
illicit drugs. Drug and Alcohol Review 25: ity for Substance Abuse Services to Reduce
611–624 Health Disparities. Presented at Society
Rogers, P.J. (2005): Logic models. In: Mathison, for Social Work and Research Meeting.
S. (ed.): Encyclopedia of Evaluation. Bev- Research That Matters (January 17 – 20,
erly Hills, CA: Sage Publications 2008). http://sswr.confex.com/sswr/2008/
Rossi, P. & Lipsey, M.W. & Freeman, H.E. techprogram/P9049.HTM
(2004): Evaluation. A systematic approach Wells, R. & Lemak, C.H. & D'Aunno, T. (2006):
(7th ed.). Thousand Oaks, CA: Sage Insights from a national survey into why
Tonigan, J. S. (2003): Project Match treatment substance abuse treatment units add pre-
participation and outcomes by self-reported vention and outreach services. Substance
ethnicity. Alcoholism: Clinical and Experi- Abuse Treatment, Prevention, and Policy
mental Research 27 (8): 1340–1344 1: 21
Treno, A.J. (2003): Environmental approaches Weiss, C.H. (1972): Evaluation Research. Meth-
to prevention. In: Graham, AV.W. & Schulz, ods for Assessing Program Effectiveness.
T.K. & Mayo-Smith, M.F. & Ries, R.K. & Prentice-Hall, Inc., Englewood Cliffs, New
Welford, B.B. (eds.): Principles of Addic- Jersey
tion Medicine (3rd ed.), Chevy Chase, MD: Wutzke, S.E. & Shiell, A. & Gomel, M.K. &
American Society of Addiction Medicine Conigrave, K.M. (2001): Cost effectiveness
Trolldal, B. & Holder, H.D. & Agnéus, H. & of brief interventions for reducing alcohol
Edin, A. (2000): Description of the Swed- consumption. Social Science & Medicine
ish alcohol system 1995–2000: Production, 52 (6): 863–870.
import, export, wholesale, and retail. In:
NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 27. 2010 . 6 563You can also read
