Substance abuse treatment as part of a total system of community response

Harold D. Holder

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

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     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

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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)

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     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

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(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

               Universal or Community Wide Approaches
               Strategies which target the entire community
               Example: Drinking and driving detterence

               indicated or identified approaches
               Strategies which target subgroups with “risk” profiles
               Example: First DUI Offenders

               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

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     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

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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

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     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

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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

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       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).

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Substance abuse treatment as part
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                                    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

                     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

Figure 2. Logic model for a comprehensive system to reduce alcohol-involved motor vehicle

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,

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Substance abuse treatment as part
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                                                                                                                              concern about
                                                                                          Meth beliefs
                                     Community norms                                                                          meth harm
                                                                                          – attitudes
                                     (enforcement & use)                                  – perceived social norms
                                                                                          – expectancies

                                           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

     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    .   6
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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:
simply not provided. As a result, without

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