THE HIGH RISK DRINKERS PROJECT

The High Risk Drinkers Project is a campus-based program for the reduction of alcohol-related problems among members of the University of Washington community (Marlatt et al., in press). This project has applied many of the principles of harm reduction to provide an alternative to traditional services for this population.

Because alcohol use is associated with normal development among students, a program was developed in which a variety of risk factors and problems are assessed but labels such as “problem drinking” or “alcoholic” are avoided. As in other harm reduction approaches, this program attempts to place both alcohol-related problems and varieties of interventions on a continuum.

Attempts are made to match individuals to levels of care based on the extent of their alcohol-related problems and, significantly, their willingness to receive any form of help or treatment. In order to test the efficacy of this approach, a longitudinal study was conducted involving more than 400 students who entered the University of Washington as freshmen in 1990 (cf. Baer 1993).

Students were selected from among the entire incoming class based on their reports of risky high school drinking or their experience of negative alcohol-related consequences prior to entering the university. Because the members of the sample are at increased risk for experiencing alcohol-related problems, this study is one of secondary prevention.

One of the features of many harm reduction programs is the utilization of low-threshold services. It is essential that the criteria for receiving services do not exceed the interest or commitment level of potential recipients.

In this sample, few students would identify themselves as candidates for any form of treatment. In order to encourage students to participate in the program, the authors have developed a userfriendly stepped-care approach that is modeled after existing therapeutic practices for hypertension (see Sobell and Sobell 1993).

The first step of the program consists of a single hour in which each subject meets with a member of the staff to receive feedback concerning his or her drinking risks and to review practices for reducing harm. Previous research has shown that brief interventions can have a significant and enduring impact on drinking habits (Baer et  al. 1992).

Subsequent levels of care are available to subjects if the initial intervention is not sufficiently effective. The therapeutic style is based largely on the principles of motivational interviewing (Miller and Rollnick 1991). This technique is designed to cultivate and strengthen an individual’s level of commitment to change.

Consistent with Prochaska and DiClemente’s (1982) model of the stages of behavior change, the motivational interviewer’s task is to help an individual advance from considering change to attempting change.

Prochaska and DiClemente (1982) describe several levels of preparedness for change that individuals may pass through: precontemplation, in which change is not being considered; contemplation, in which the idea of changing emerges; action, in which some attempt to change is made; maintenance, in which successful actions are maintained; and relapse, in which the previous undesired behavior reemerges.

Consistent with harm reduction, any movement toward taking and maintaining action is viewed positively. Preliminary results of this ongoing project indicate that students assigned to the stepped-care program reported significantly lower levels of drinking after 2 years than students in a randomly assigned comparison group (Marlatt et al., in press).

A measure of alcohol-related problems (the Rutgers Alcohol Problem Index; White and Labouvie 1989) recorded a similar decline among students receiving this intervention versus a comparison group. Consistent with the above mentioned motivational orientation, a considerable part of clinical attention goes toward maintaining good rapport with the subjects.

If an individual continues to report risky drinking practices or negative consequences of alcohol use subsequent to the initial interview, the student is advised and an attempt is made to engage the individual in a discussion of what might be the best course of action to take.

A range of options is presented, but the decision to undertake any action is left to the student. This clinical style is informed by a body of research in the addictions field that underscores the importance of commitment to change as a contributor to the ultimate success of any program (Hall et al. 1990, 1991). Certain parallels may be evident between this secondary prevention program, programs such as needle exchange to prevent the spread of  HIV, and tertiary prevention programs such as the mobile methadone clinics in Amsterdam.

In each case, the program makes an attempt to enter the lives of the persons who might benefit from its services. The practitioners of these programs, like therapists of many schools, are advocates for the individuals they serve. Services and information are made available but are not forced on people.

For example, the workers who staff Amsterdam’s mobile methadone clinics become personally familiar with many of the addicts that they serve and offer encouragement for change in addition to multiple services such as exchanging needles, administering oral doses of methadone, and providing condoms and first aid supplies.

A great benefit of this approach is that a large proportion of the target population is in contact with some form of health promotion agency (Marlatt and Tapert 1993). In Amsterdam, it is estimated that 60 to 80 percent of IDUs are in contact with health agencies (Engelsman 1989, p. 217).

This proximity greatly enhances the opportunities for care that may be administered. It also illustrates a type of societal response to drug-related problems that avoids alienating individuals by identifying them as either sick or criminal, but seeing them instead as people who are part of society and who need help.

HARM REDUCTION AND AMERICAN DRUG POLICIES

In 1992, the United States budgeted $11,680 million for Federal drug programs, 70 percent of which was allotted to interdiction and law enforcement and 30 percent of which went toward education and treatment programs. This division of resources will do little to reduce the numerous impediments to treatment for addicts and IDUs in the United States.

More than 107,000 individuals were on waiting lists for treatment in 1991 (National Commission on AIDS 1991), but there are vastly more individuals who might benefit from some care. New York City has an estimated 200,000 IDUs but only 38,000 publicly funded treatment positions.

Inadequate funding is only one of the factors that limits access to proper health care for drug users: needle exchange programs remain illegal in many cities and States; most treatment programs require abstinence as a condition of admission or continuation of services; the most widely available forms of treatment in the United States tend to incorporate disease model concepts or  involve submission to a “higher power,” which many individuals find personally objectionable; and the threat of arrest and possible imprisonment for use deters many (e.g., pregnant females who may fear prosecution for child abuse).

In contrast to low-threshold policies advocated under harm reduction. U.S. drug policy sets a very high threshold on drug-related services. Beyond the harm that is done by underfunding treatment and educational programs, it is apparent that considerable harm is being added, rather than alleviated, by spending vast sums on interdiction and law enforcement.

The persecution of addicts and recreational drug users alike is exacting an inconceivably high toll and is fiscally irresponsible because prison is a tremendously expensive form of treatment that is also demonstrably ineffective.

NOTE This paper is based on material from the chapter “Harm reduction: Reducing the risks of addictive behaviors” by G.A. Marlatt and S.F. Tapert in Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds. Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues. Newbury Park, CA: Sage Publications, 1993. pp. 243-273.

REFERENCES

Anderson, J.E.; Kann, L.; Holtzman, D.; Arday, S.; Truman, B.; and Kolbe, L.J. HIV/AIDS knowledge and sexual behavior among high school students. Fam Plann Perspect 22:252-255, 1990.

Baer, J.S. Etiology and secondary prevention of alcohol problems with young adults. In: Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds. Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues. Newbury Park, CA: Sage Publications, 1993. pp. 111-137.

Baer, J.S.; Marlatt, G.A.; Kivlahan, D.R.; Fromme, K.; Larimer, M.; and Williams, E. An experimental test of three methods of alcohol risk-education with young adults. J Consult Clin Psychol 60:974- 979, 1992. 

Battjes, R.J., and Pickens, R.W. Needle sharing among intravenous drug abusers: Future directions. In: Battjes, R.J., and Pickens, R.W., eds. Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. National Institute on Drug Abuse Research Monograph 80. DHHS Pub. No. (ADM)88-1567. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 176-183.

Benowitz, N.L. Drug therapy: Pharmacologic aspects of cigarette smoking and nicotine addiction. New Engl J Med 319:1318-1330, 1988.

Brettle, R.P. HIV and harm reduction for injection drug users. AIDS 5:125-136, 1991.

Brownell, K.D., and Foreyt, J.P., eds. Handbook of Eating Disorders. New York: Basic Books, 1986.

Canadian Center on Substance Abuse. Harm reduction strategies: Smokable drugs help reduce spread of HIV in Merseyside. News Action 11(4):7, 1991.

Centers for Disease Control. HIV/AIDS Surveillance Report. Atlanta: Division of HIV/AIDS, National Center for Infectious Diseases, Centers for Disease Control, April 1992.

Chaney, E.F., and Roszell, D.K. Coping in opiate addicts maintained on methadone. In: Shiffman, S., ed. Coping and Substance Use. Orlando, FL: Academic Press, 1985. pp. 267-292.

Dolan, M.P.; Black, J.L.; Penk, W.E.; Robinowitz, R.; and DeFord, H.A. Contracting for treatment termination to reduce illicit drug use among methadone maintenance treatment failures. J Consult Clin Psychol 53:549-551, 1985.

Durst, M.E. “Statement Presented on Behalf of the National Council on Juvenile and Family Court Judges.” Presented at the Open Meeting of the I.O.M. Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Washington, DC, January 1988.

Eigen, L.D., and Quinlan, J.W. OSAP college drinking campaign: “Put on the brakes: Take a look at college drinking!” Alcohol Health Res World 15:87-89, 1991.

Engelsman, E.L. Dutch policy on the management of drug-related problems. Br J Addict 84:211-218, 1989. 

Fillmore, K.M.; Bacon, S.D.; and Hyman, M. The 27-Year Longitudinal Panel Study of Drinking by Students in College, 1949-1976. Final report to National Institute on Alcohol Abuse and Alcoholism (Contract no. ADM 281-76-0015). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1979.

Gross, J., and Stitzer, M.L. Nicotine replacement: Ten-week effects on tobacco withdrawal symptoms. Psychopharmacology 98:334-341, 1989.

Hall, S.; Havassy, B.; and Wasserman, D. Commitment to abstinence and acute stress in relapse to alcohol, opiates, and nicotine. J Consult Clin Psychol 58: 175-181, 1990.

Hall, S.; Havassy, B.; and Wasserman, D. Effects of commitment to abstinence, positive moods, stress, and coping on relapse to cocaine use. J Consult Clin Psychol 59:526-532, 1991.

Heather, N., and Robertson, I. Controlled Drinking. London: Methuen, 1983.

Heather, N.; Wodak, A.; Nadelmann, E.; and O’Hare, P., eds. Psychoactive Drugs and Harm Reduction. London: Whurr Publishers, 1993.

Higgins, S.T.; Stitzer, M.L.; Bigelow, G.E.; and Liebson, I.A. Contingent methadone delivery: Effects on illicit-opiate use. Drug Alcohol Depend 17:311-322, 1986.

Holtzman, D.; Anderson, J.E.; Kann, L.; Arday, S.L.; Truman, B.I.; and Kolbe, L.J. HIV instruction, HIV knowledge, and drug injection among high school students in the United States. Am J Public Health 81:1596-1601, 1991.

Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990.

Johnston, L.D.; Bachman, J.G.; and O’Malley, P.M. Drug Use, Drinking and Smoking: National Survey Results From High School, College, and Young Adult Populations. DHHS Pub. No. (ADM)89-1638. Rockville, MD: National Institute on Drug Abuse, 1991.

Johnston, L.D.; O’Malley, D.M.; and Bachman, J.G. Drug Use, Drinking and Smoking: National Survey Results From High School, College, and Young Adult Populations, 1975-1988. DHHS Pub. No. (ADM)89-1638. Rockville, MD: Alcohol, Drug Abuse, and Mental Health Administration, 1989. 

Kusserow, R.P. Youth and Alcohol: National Survey: Drinking Habits, Access, Attitudes, and Knowledge. DHHS Pub. No. OEI-09-91-00652. Washington, DC: Office of the Inspector General, 1991.

Marks, J. The practice of controlled availability of illicit drugs. In: Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the Addictive Behaviors. New York: Maxwell Macmillan International Publishing Group, 1991. pp. 304-316.

Marlatt, G.A. The controlled drinking controversy: A commentary. Am Psychol 38:1097-l110, 1983.

Marlatt, G.A. “Executive Summary: College Students as a High Risk Group.” Summary prepared for the Institute of Medicine Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, April 1988.

Marlatt, G.A.; Larimer, M.E.; Baer, J.S.; and Quigley, L.A. Harm reduction: Moving beyond the controlled drinking controversy. Behav Ther, in press.

Marlatt, G.A., and Tapert, S.F. Harm reduction: Reducing the risks of Addictive Behaviors. In: Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds. Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues. Newbury Park, CA: Sage Publications, 1993.

Mavis, B.E.; DeVoss, G.H.; and Stoffelmayr, B.E. The perceptions of program directors and clients regarding the efficacy of methadone treatment. Int J Addict 26:769-776, 1991.

Miller, W.R.; Leckman, A.L.; Delaney, H.D.; and Tinkcom, M. Long-term follow-up of behavioral self-control training. J Stud Alcohol 53:249-261, 1992.

Miller, W.R., and Page, A.C. Warm turkey: Other routes to abstinence. J Subst Abuse Treat 8:227-232, 1991.

Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People for Change. New York: Guilford, 1991.

Nathan, P.E., and McCrady, B.S. Bases for use of abstinence as a goal in the behavioral treatment of alcohol abusers. Drugs and Society 1:109-131, 1987.

National Commission on AIDS. The Twin Epidemics of Substance Use and HIV. Washington, DC: National Commission on AIDS, 1991. 

National Institute on Alcohol Abuse and Alcoholism. Report of the 1983 Prevention Planning Panel. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984.

O’Hare, P.A.; Newcombe, R.; Matthews, A.; Buning, R.C.; and Drucker, E. The Reduction of Drug-Related Harm. London: Routledge, 1992.

Parry, A. Harm reduction. The Drug Policy Letter (Washington, DC: The Drug Policy Foundation) 1, no. 4 (1989):13.

Prochaska, J.O., and DiClemente, C.C. Toward a comprehensive model of change. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors. New York: Plenum Press, 1982. pp. 3-27.

Russell, M.A.H. The future of nicotine replacement. Br J Addict 86:653-658, 1991. Shedler, J., and Block, J. Adolescent drug use and psychological health: A longitudinal inquiry. Am Psychol 45:612-630, 1990.

Sobell, M.B., and Sobell, L.C. Behavioral Treatment of Alcohol Problems. New York: Plenum Press, 1978.

Sobell, M.B., and Sobell, L.C. Treatment for problem drinkers: A public health priority. In: Baer, J.S.; Marlatt, G.A.; and McMahon, R.J., eds. Addictive Behaviors Across the Lifespan: Prevention, Treatment, and Policy Issues. Newbury Park, CA: Sage Publications, 1993. pp. 138-160.

Sorenson, J.L.; Wermuth, L.A.; Gibson, D.R.; Choi, K.H.; Guydish, J.R.; and Batki, S.L. Preventing AIDS in Drug Users and Their Sexual Partners. New York: Guilford, 1991.

Stimson, G.V. Syringe-exchange programmes for injecting drug users. AIDS 3:253-260, 1989.

Stitzer, M.L.; Bickel, W.K.; Bigelow, G.E.; and Liebson, I.A. Effect of methadone dose contingencies on urinalysis test results of polydrug-abusing methadone-maintenance patients. Drug Alcohol Depend 18:341-348, 1986.

Walter, H.J.; Vaughan, R.D.; Gladis, M.M.; Ragin, D.F.; Kasen, S.; and Cohall, A.T. Factors associated with AIDS risk behaviors among high school students in an AIDS epicenter. Am J Public Health 81:528-532, 1991.

Wechsler, H., and Isaac, N. “Binge” drinkers at Massachusetts colleges: Prevalence, drinking style, time trends, and associated problems. JAMA 267:2929-2931, 1992.

White, H.R., and Labouvie, E.W. Towards the assessment of adolescent problem drinking. J Stud Alcohol 50:30-37, 1989. 

Woltzen, MC.; Filstead, W.J.; Anderson, C.L.; Twadell, S.; Sisson, C.; and Zoch, P. Clinical issues central to the residential treatment of alcohol and substance misusers. Adv Adolesc Ment Health 2:271-282, 1986.

AUTHORS

G. Alan Marlatt, Ph.D. Professor of Psychology and Director The Addictive Behaviors Research Center

Julian M. Somers, M.S. Graduate Research Assistant

Susan F. Tapert, B.A. Undergraduate Research Assistant Department of Psychology University of Washington Seattle, WA 98195

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From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]