The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.
Includes a trenchant critique of the kind of cost-benefit calculations which have influenced national alcohol policy, a resource-light way to deliver alcohol interventions at emergency departments, and a review and first evaluation of positive psychology in the treatment of substance use problems.
Nordic Studies on Alcohol and Drugs: 2012, 29, p. 321–343.
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Prominent alcohol expert argues that estimates that drinking imposes billions of pounds of costs on society are so value-laden and imprecise that their main value is as propaganda. Policies like increasing the price of drink may be justified on other grounds, but not by a misleadingly appealing total cost or cost reduction figure.
Summary This analysis argues that estimates of the cost imposed on society by drinking are often grossly inflated because (among other things) they assume that hazardous drinking must be irrational consumption, that crime benefits no one, that drinking has no social, psychological or indirect business benefits, and that productivity losses are not counter-balanced by benefits elsewhere and by non-alcohol impaired workers taking over the jobs of the impaired. These assumptions are, it is contended, based on value judgements sometimes not made explicit, and lend the results of calculations based on those values a spurious appearance of objectivity and precision.
In bold in the following account are some cost headings which arguably should not (or not fully) be included in the grand total for society as a whole but which have been in various reports. Cumulatively they make a substantial difference to cost estimates.
Reports on Australia and New Zealand effectively assumed that if someone has spent money in order to drink at levels which risk harm, they must have done so through ignorance or irrationality, rather than this representing an informed purchase which from the drinker's point of view gains benefits at least worth their expenditure. With no countervailing benefits, expenditure on 'excessive ' drinking is treated merely as waste and a loss to society. This decision has a considerable impact on the grand total of tangible social costs due to alcohol, in the Australian report accounting for over 15% and 10% in the New Zealand report.
Heavy drinking may be hazardous, irresponsible or even morally wrong, but not necessarily irrational. The contention that heavier consumers are ill-informed requires evidence; it cannot simply be assumed. Nor can we assume that the only pros and cons a drinker can take in to account and remain rational are related to health, not social networking, relaxation, making business contacts, enjoyment of intoxication, etc. A rational and fully informed consumer may judge these worth increased health risks. If all behaviours which increase health risk are irrational and/or ill-informed, we would have to include playing ice hockey or travelling by car instead of train, not normally considered inherently irrational or lacking benefits.
A related but different issue concerns addicted drinkers. Even if their behaviour may in some sense be less than fully rational, their spending on drink is best classified as a private cost borne by them. The argument that it is a social cost rests on the assumption that the adverse consequences actually experienced are greater than those anticipated at the time of purchase. The difference is categorised as a social cost because the drinker did not account for these unintended consequences when they decided it was worth buying the drink. But there is a risk element in most everyday decisions, yet not all unanticipated and unintended costs are treated as social costs.
Calculations also sometimes treat the value of stolen property as a loss to society. From the perspective of the whole society (one advocated by the cost-of-alcohol literature) this overlooks the revenue of the thief and others who benefit from the theft. An alternative assumption, made for example in an estimate for Sweden, is to count as social costs the difference between what the thief gets for the goods and their market price. This still ignores the profits of the 'fence' and particularly the value gained by the end purchaser who enjoys the object's use without having to pay the full price. Instead of taking a whole society approach, we could estimate the losses caused to 'decent' or 'ordinary' people, but this should not then be added to the total for society as a whole. The value of stolen property is
Editor's note: called by economists a 'transfer payment'. See for example this analysis of the "Pharmaco-economics of community maintenance for opiate dependence":
which says, "losses from criminal activity in fact constitute a transfer payment within society rather than impose an additional cost on society and, hence, should not be counted from a societal perspective". within society, not lost altogether.
Production lost due to premature mortality is the largest item in most cost calculations, but World Health Organization guidelines published in 2010 say this "should not be included" [Editor's note: largely because it is assumed that the loss amounts to lost work over what would have been the entire productive life of the deceased, yet in the absence of full employment, their place will usually be taken (if via a chain of job moves) by someone who would otherwise have been unemployed].
The Sheffield Alcohol Policy Model [Editor's note: on which British alcohol pricing policy proposals have been largely been based; see for example this Findings analysis] may be equally controversial. "Workplace harms" included in the model consist of alcohol-related unemployment and absence from work. First the analysts calculate the increased risk that someone will be unemployed the more they drink above harmful levels. They then take a step too far Of which they are not unaware: "Note that the estimated unemployment effects are based on evidence of association studies, rather than detailed prospective analysis of the dynamic effects of employed people becoming unemployed as a consequence of their drinking behaviour, or of unemployed people becoming employed again as consequence of reductions in alcohol consumption. The benefits estimated make no assumption about the directions of these effects and there is no analysis of how the current economic climate might affect these findings." when they use this to predict that (for example) a minimum unit price for alcohol of £0.50 would lead to 25,900 fewer people unemployed in the first year. Drinking may affect who gets hired and fired first, but a minimum unit price would hardly create 25,900 new jobs. This assumption has a substantial impact, accounting for three quarters of the estimated social value gained by a £0.40 minimum price in year one.
Calculations of losses due to absenteeism take no account the benefits the drinker and perhaps others gain from staying away from work. Arguably the value lost to the company and the economy is transferred in a different form to the worker and others who are able to enjoy a day off work or enjoy a night's drinking knowing they can sleep it off the next morning.
Estimates have recently been made of the diminished quality of life caused by drinking to people other than the drinker. Important as this is, it is also important to keep in mind that attitudes affect responses. It is for example possible As may have happened with smoking. that as toleration of heavy drinking declines so too does heavy drinking, yet the distress felt by others witnessing heavy drinking might increase. In this scenario, distress caused to others rises as heavy drinking falls. It is a matter of judgement whether it makes sense to include this in social cost calculations. Again, monetarisation tends to hide the impact of this kind of value judgement. Values and moral judgements influence what it seems legitimate or 'natural' to include in estimates of intangible costs. For example, it may seem natural to include being kept awake or harassed by a drunk, yet not the shame felt by the caregivers of schizophrenia patients due to the mental illness of their child or relative.
Monetary values have also been attached to the degree to which the public would prefer not to experience drinking conditions ranging from being a non-drinker through to an at-risk drinker and being alcohol dependent, bringing in to play the imaginings of the unafflicted Though in the US report referred to below there was no statistically significant difference between the ratings given by 'at-rsk' drinkers and others. Still the authors speculated that "stigma, negative perceptions, and religious beliefs about alcohol consumption may play a role in the low utility values for alcohol abuse and alcohol dependence and explain why some participants gave low utility ratings to moderate drinking and at-risk drinking". In addition, they speculate that their results might have been different had the way they described alcohol abuse and dependence to the participants included text "lauding the positive or enjoyable aspects of alcohol use". of what these conditions would feel like, creating a mechanism for stigma, unwarranted negative perceptions, and religious beliefs, to feed in to the cost calculations. In a Swedish study these ratings were derived from a US report based on judgements made two samples of 100 respondents not necessarily representative of the broader population. The authors were surprised by the low health ratings given to at-risk drinking, defined as entailing no significant adverse consequences. Alcohol abuse was rated as low as being blind, dependence lower still. The implication is that alcohol abusers would be willing to trade becoming blind in order to cease being abusers and dependent drinkers would be eager to do so.
The Swedish study applied the US ratings for alcohol dependence to harmful consumption, despite the fact that many such drinkers would not see themselves as suffering the symptoms by which dependence was defined. Including needing to drink to "get rid of the shakes" and drinking despite medical advice that drink has "damaged your liver". Additionally, there is disagreement about the monetary value to attach to these states of health. With so many layers of uncertainty and value judgements involved, we cannot have any faith in the resultant estimate of the monetary value of the diminished health-related quality of life associated with heavy drinking. As long as the calculations remain within the confines of public health this does not cause serious problems. But a further and complicating step is taken when (as in UK calculations) these estimates are then added to those related not to health, but, for example, to productivity.
An example of how cost-of-alcohol studies gain their results through limiting their vision comes from a California study which included an estimate for unwanted pregnancies due to unprotected sex under the influence of drink. Its source documents account for medical costs and the mother's lost productivity, but fail to account for the counterbalancing productive potential of the child.
Cost studies usually limit themselves to the adverse consequences of drinking, and include benefits (if at all) only in terms of health. This is fine if health is the limit of the study, but as the World Health Organization explains, if the study purports to assess total costs across a society, then there is no rationale for excluding benefits. Some benefits may be intangible, but so too are some of the adverse consequences costed in to the studies. Among the pleasures/value of drinking for drinkers are taste, food value, enjoyment of an altered state of consciousness, and greater expressiveness. Then there are social rewards linked to drinking such as the pleasure given to dinner guests, the solidarity of round-buying and drinking 'buddies', drink as a way of forging sexual and other relationships, and beyond these the business benefits of wining and dining clients and broader social cohesion. Some town centres owe their lively character to drinking venues.
One way to assess these is by calculating how much more consumers would be prepared to pay for drink. This figure is for them the net benefit after taking in to account how much they actually do spend. The figures can be derived from studies of how much consumption rises/falls in response to price changes. One such exercise arrived at an estimate However, the underlying assumption that consumers would be prepared to pay 50% more for their drink is close to arbitrary. that drinking's pleasures and other benefits are worth £2309 million to London's drinkers – greater than the report's estimate of the cost of alcohol-related crimes.
Heavier drinkers are usually less responsive to price increases than less heavy drinkers. According to the methodology just described, this translates in to their gaining greater benefits per unit they drink. Sometimes an attempt is made to discount these benefits by arguing excessive drinkers must be irrational or ill-informed, and that their pleasures are therefore illusory or counter-balanced by adverse consequences they have failed to appreciate – an unwarranted assumption dealt with above.
Another in practice unaccountable factor is what consumers who stop drinking due to price increases do with the money they save. They may lose the benefits as they see them of drink, but gain others. What these might be and how they should be valued would require an extensive research programme of dubious value because it would feed in to a set of calculations which for other reasons (as argued in this analysis) cannot be relied on.
The practical impossibility of monetarising such benefits does not mean they can be ignored. It simply highlights the futility of attempting to assess the total social costs of alcohol in a meaningfully comprehensive manner.
If questionable assumptions and imprecision render cost-of-alcohol estimates of little scientific worth, the question arises why such studies are funded and undertaken. The most important reason is their political value, because "the allocation of public funds between competing programs is substantially influenced by public servants trained in economics or finance". Present cost estimates are so crude that from a policy perspective their worth is mainly limited to this propaganda value. How crude they are can be appreciated from estimates that alcohol costs as a proportion of the gross domestic product differ nearly fourfold between Spain and New Zealand, with the latter being the highest despite lower consumption.
Cost-of-illness studies can be seen as weapons in an armaments race as each health sector strives to show that the problem it is charged with ameliorating matters more than alternative spending priorities. Because the comparability issues are at their least, this comes closest to being justified in the attempt to show that alcohol is a bigger problem than illicit drugs. However, the same point could be made with more accurate and more easily available figures on morbidity and mortality or on public expenses related to alcohol and drugs.
Another commonly cited purpose of cost-of-alcohol studies is to provide a way to assess the effectiveness of intervention policies, either in terms of their cost-effectiveness in producing desired outcomes per extra £ spent on the interventions or their cost-benefit credentials in reducing the total cost imposed by drinking. Here too, there seems no reason why more direct data such as such as government expenditure, mortality figures, crime statistics and drinking surveys could meet the same need more reliably.
Two such analyses (an original study and an update) conducted for the World Health Organization assessed effectiveness in terms of gains in years of life adjusted for the degree of disability experienced during those years. Their calculations are based on so many arbitrary and unrealistic assumptions that their policymaking value is highly doubtful. For example, the earlier analysis assumed that price increases reduce consumption most for the type of drink least often consumed in a country, while the most popular type of drink is much less affected. The result was that in parts of Europe wine drinking was assumed to react little to price while in others the reaction was five times as strong, despite the fact that in both regions wine accounted for a substantial minority of the alcohol consumed. This assumption also meant that price increases were assumed to be relatively ineffective when the alcohol market was dominated by one type of drink, as in the South East Asian region where distilled spirits accounted for over 85% of all consumption.
The update analysis inherited many of the uncertainties of its predecessor and added some surprising cost comparisons, such as that school-based education is for some reason 83% more expensive in Vietnam than in Brazil, while mass media campaigns are 63% more expensive in Brazil. It also assumed that research findings on the impact of an intervention in one cultural and national context can be extrapolated to others. It is bold indeed to assume that an increase in the age at which alcohol can legally be bought would have the same impact in say Italy as in the United States, or that price increases would have the same impact in, say, Vietnam and Scandinavia. Intervention costs too are (unrealistically) assumed to be the same in all countries in a region, despite the fact that regions are formed of countries with similar mortality levels, not similar costs.
A different example of the limits of economic modelling comes from the mathematical model which has influenced policy in Britain. It calculates that screening primary care patients for hazardous drinking and briefly counselling those at risk is a cost-effective way to reduce mortality and morbidity, with associated impacts on healthcare costs and health-related quality of life. However, no account is taken of the uses which the time spent in these activities could have been put to. As the medical journal the Lancet critically observed, "lecturing" patients about lifestyle takes up time in the average 12-minute GP consultation which could have been used to address the reason why the patient attended in the first place, or some other medical condition. These uses might have more cost-effectively reduced ill-health than a diversion to drinking. Such considerations do not invalidate the findings of the modelling exercise, but do show that it is inherently limited because it cannot account for all the alternative uses of a GP's and a patient's time, the best use of which perhaps the participants are best placed to judge.
The background notes detail further (it is contended) invalid or unnecessary uses of total cost studies including: comparing alcohol-related costs to those related to other illnesses such as mental illness; comparisons between the costs associated with drinking in different countries; and targeting policy at the most costly forms of drinking.
Even the most sophisticated cost-of-alcohol calculations include entries based on misleading assumptions or logical mistakes. Monetary calculations do not add precision to the comparison of the magnitude of health problems. Cost calculations cannot be used to compare the extent or nature of alcohol problems in different countries. Cost calculations should focus on money spent from clearly defined budgets. It is good to measure the joys and sorrows of heavy drinkers and their nearest, but little is gained from expressing them in euros and dollars. The use of a monetary metric conceals important issues and value judgements. Traditional measures of alcohol problems offer a better picture of the effects of policy measures than cost-of-alcohol estimates.
There is no meaningful way to compare the sufferings of a child with born damaged due to their mother's drinking to the sufferings of youngster put in a wheelchair because of a drunken driver. The allocation of resources to alleviate these different forms of sufferings is, and has to be, based on value judgements in addition to any cost calculations. Value judgements should not be hidden behind a curtain of opaque calculations. Many of the variables needed for cost-of-illness estimates, such as hospital days, arrests for drunkenness, number of deaths and QALYs lost, are useful measures of the tangible effects of alternative interventions. Only exceptionally is there reason to translate them into a grand total in money terms. Usually, a more rational way of choosing between alternatives is to compare effect profiles as such. Intangible costs may be measurable in principle, but in practice the measures available are not accurate enough to be used in policy evaluations.
commentary Among other roles, the author was Research Director of the Finnish Foundation for Alcohol Studies and Professor of Sociology at Helsinki University. In the middle of the firing line of his iconoclastic critique are attempts to calculate a single monetary value for the costs imposed on society by drinking. These headline-grabbing figures are major weapons in policy setting debates, promising at times vast returns to society for relatively little expenditure in curbing drinking. If they are indeed invalid and/or hugely imprecise, to that degree policy based on them will also risk being significantly misguided. Though some shots stray towards these, the featured analyst finds much greater validity in attempts to cost interventions and set these against 'natural units' of losses and benefits such as life-years saved or injuries or crimes averted.
The implication of the featured analysis is that while component policies like health service priorities may be susceptible to cost-effectiveness analysis, whole-society policy like minimum per-unit pricing or restricting licensing cannot (at least given the current state of the science) reliably be decided by analyses which purport to show that the returns from these policies are greater than the costs. The alternative is to weigh in the balance several consequences of implementing such policies. This means that, as the featured analysis points out, data about which interventions affect which outcomes must be refracted through the prism of which outcomes we value most, and whose values have the greatest leverage in determining policy. Its principle objection to cost estimates is that these typically are not explicit about the values behind them, and that the false precision of a numerical estimate gives an appearance of a value-free calculation.
Possibly in view of the significance and contentious nature of this critique, alongside it were published six responses, including the views of the some of the world's leading alcohol researchers, and some responsible for cost estimates the featured analysis criticised. Broadly they supported the thrust of the critique, though argued that despite its scientific imprecision or conceptual invalidity, calculating a total cost figure does aid policymaking because it gives an indication of the overall size of a problem relative to others. Without some such common metric, comparisons are much more complicated and less convincing to public and policymakers – the reason why such studies are commissioned.
A critique similar to the featured study was published the same year (2012) in New Zealand, focusing on two of the same cost-of-alcohol reports – the ones for Australia and New Zealand. The authors accepted that attaching a figure to the costs drinking imposes on others is a valid way to determine how much people should have to pay in alcohol taxes for imposing those costs. But they calculate that such costs are in fact just a fifth of the totals estimated by the two reports.
The core of the critique is that the adverse consequences experienced by drinkers themselves should normally be considered offset by the benefits they gain; consequences are among the 'costs' they are prepared to 'pay' for the benefits. To do otherwise is the same, they suggest, as treating skiing as utterly socially wasteful because only the accident costs suffered by skiers are considered while taking no account of the fact that that skiers generally derive at least some enjoyment from their risky activity. This blanking out of benefits is, as the featured analysis says, sometimes justified on the basis that risky drinkers must be ill-informed or irrational consumers. For the New Zealand critique this is like assuming that "imperfect information in the used car market means nobody derives any benefit from buying a vehicle". The critique also agrees with the featured study that lost productivity estimates fail to account for the replacement of the alcohol-impaired or prematurely dead worker by another.
The study underlying the article was commissioned and funded by an alcohol industry body. Earlier the same authors had published an extended critique of the New Zealand study. The lead author has also released a more trenchant and informal critique.
For British readers, criticisms levelled at the Sheffield University modelling exercise are most pertinent. Applied to England and Scotland, this fed in to decisions to set a minimum unit price for alcohol, among the most significant policy decisions in living memory.
The headline figures summing up the exercise were expressed in total cost terms. For example, for England, over ten years the cumulative value of the net harm reductions caused by a £0.40 minimum price were estimated at £540 million, more than doubling to £1.3 billion at a £0.50 threshold. For the featured analysis, these figures are virtually worthless, in particular because they are dominated by cost savings due to reduced unemployment, calculations which effectively assume that no one currently unemployed benefits from the vacancies left by drinkers.
By design too, the estimates exclude what the researchers described as drinking's "beneficial effects in terms of individual 'feel good' factors or general quality of life". Subjective 'feel bad' consequences were included, for example in the form of distress caused to the victims of crime and diminished quality of life due to alcohol-related illness. According to the World Health Organization, if one is included, so should the other be if the aim is to assess the total net harm imposed on society by drinking. This omission of what for probably most of the population are the main reasons for drinking has been highlighted by Findings as a flaw not in the study itself, but in the use of these results in isolation to determine social and economic policy.
An alternative position taken by a UK government analysis published in 2003 is that diminished quality of life due to alcohol-related illness is part of the cost drinkers are prepared to pay, so from a whole society perspective, is cancelled out by the benefits they experience. As for the other critics, the argument is that only the consequences and benefits arising for other people are relevant to determining public policy.
Findings has also highlighted the implicit assumption that crime benefits no one and in particular that stolen property effectively vaporises rather than being transferred within society. Though a factor (as the featured analysis says) in alcohol cost estimates, this assumption is particularly significant in estimates of the cost imposed by addiction (and saved by its treatment) to illegal drugs, whose purchase is often funded by prodigious levels of property crime.
The point made in the featured analysis that time spent in primary care screening and brief intervention targeted on drinking might have more profitably been used in other ways is applicable to most brief intervention studies, which limit themselves to the their specific topic without looking at the totality of the primary care encounter. Again this not a criticism of the studies themselves, but of their use in isolation to determine (in this case) health policy.
Such considerations do not invalidate the more concrete constituents which fed in to Sheffield model's total cost estimates, such as lives saved, crimes not committed, and illnesses avoided. These in themselves may be considered a good enough reason to curtail the availability of alcohol, even if some drinkers are thereby deprived of the benefits they feel they get from drinking, or pay more to sustain these and lose out in the form of less money for other purposes.
Thanks for their comments on this entry in draft to Klaus Mäkelä of Helsinki in Finland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 20 October 2012. First uploaded 13 October 2012
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Havard A., Shakeshaft A.P., Conigrave K.M. et al.
Alcoholism: Clinical and Experimental Research: 2012, 36(3), p. 523–531.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Havard at firstname.lastname@example.org.
At Australian emergency departments, screening followed by written personalised feedback mailed to risky drinkers led to at least a short-term cutback in their drinking, but only when they saw or had cause to see drink as contributing to their medical misfortune. This low cost written option demanding little of staff may make intervention more feasible.
Summary Despite their potential to reduce drink-related harm, attempts to incorporate brief alcohol interventions into emergency department routines have been hampered by substantial financial and time constraints and staff resistance to providing face-to-face feedback and counselling or advice about drinking. Employing an alcohol health worker is likewise beyond typical financial resources. Written advice reduces these demands on staff and on staff time. Studies (1 2) suggest that personalising written advice is critical to effectiveness, consistent with the enhanced impact of tailoring in changing health behaviours generally.
Although promising, the cost of achieving personalisation through computerised screening and feedback and the logistics (for example, of ensuring privacy) are still likely to be prohibitive in most departments. A low-cost alternative is to mail written personalised feedback after brief screening. Such feedback has been associated with reduced alcohol consumption in problem drinking college students, employees, and the general population, but has not been evaluated in emergency department patients. The featured study addresses this gap by measuring the short-term efficacy and cost-efficacy of mailed personalised feedback to problem drinking emergency department patients.
Participants were recruited from departments in five rural communities in New South Wales in Australia already involved in a community-wide approach to reducing alcohol-related harm. The five were asked because they had electronic medical records. Screening interviews were conducted with patients aged at least 14 years. They were told it was a phone survey of drinking conducted by researchers independent of the hospital. Patients identified as risky drinkers through screening were invited to participate in follow-up surveys. Those who agreed were randomly assigned to be sent mailed feedback on average a week later or to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group who received no further contact until both groups were phoned six weeks later for the follow-up interview.
The feedback intervention took the form of a letter from the research project presenting sex-specific charts contrasting the patient's scores with the averages in the five communities in respect of drinking quantity and frequency, frequency of heavy drinking, experience of alcohol dependence symptoms, and experience of negative consequences. Then the recipients were told that changing drinking was possible, citing relevant evidence. The letter concluded with a summary of the Australian drinking guidelines, strategies for reducing consumption, and sources of advice.
During the recruitment period 2610 patients aged 14 years or more attended the department but 1008 were there too little time or too ill or distressed to be approached. Of the rest, 1415 completed screening using the AUDIT questionnaire and 455 were identified as risky Scoring eight or more. drinkers. The 304 who consented to follow-up interviews were randomly allocated, 150 to feedback and 154 to the control group. Typically they were nearly 30 years of age and drank 160g (20 UK units) a week, and three quarters were men. About a quarter (the 'alcohol-involved' presentations) said they had drunk in the six hours before becoming unwell or thought alcohol had contributed to their condition. Follow-up interviews were completed with 80% of participants, 124 feedback patients and 120 from the control group. Rather than the usual 12 months, they were asked about the past six weeks, the time since their attendance at the emergency department.
Based on the responses of the 244 people who could be followed up, those given mailed feedback had at follow-up significantly reduced the amount they drank relative to control group patients. They were also less likely to be drinking above Australian guidelines, but this difference was not statistically significant.
The significant difference in alcohol intake was due to impacts among the minority of patients with alcohol-involved emergency attendances. Among these patients, at follow-up those sent feedback drank less than half the number of drinks per week than control group patients (11.9 v. 24.1), a medium effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. of 0.59. Among these patients, providing feedback cost 0.48 Australian dollars for every 10g alcohol less they drank at follow-up than control group patients. Impacts of the intervention were not significantly altered by the patient's sex, education level, how much they typically drank before the study, or their pre-study symptoms of alcohol dependence.
Another analysis was confined to the 71% sent feedback and the 89% in the control group who correctly recalled whether or not they had received mailed feedback. Results were similar in respect of reduced drinking amount, but among women, feedback participants also drank heavily significantly less often than those not sent feedback. Of the feedback participants who recalled receiving the letter, 87% read at least some of it and, of those, 76% found it somewhat or very useful, and 77% thought the hospital should provide this information.
This study tested an inexpensive brief intervention method which made minimal demands on emergency staff by using mailed feedback. It reduced drinking among risky drinking patients whose attendance was related to drinking, and cost less (and less to achieve a given reduction) than brief face-to-face counselling.
One question is why the significant impacts were confined to patients had drunk in the six hours before becoming unwell or thought drinking was a contributing factor. From previous research (1 2), it seems that the patients’ attribution of their condition to alcohol may be the decisive factor.
The cost analysis suggests mailed feedback represents a good investment relative to face-to-face interventions. The direct cost was 5.83 Australian dollars per patient compared to 135 US dollars for a face-to-face option. Similarly, among the group for whom it worked (patients with an alcohol-involved attendance), cost per unit less it led patients to drink must have been far lower.
In contrast to findings on drinking amount, findings on the frequency of heavy drinking were less conclusive, significant effects being limited to women who were correctly aware of having received or not the feedback. The possibility that these patients somehow differed from the remainder in ways which biased this result cannot be dismissed. It is also conceivable that seeing their drinking compared to the average led feedback patients to later under-report how much they drank. Many patients were too ill or distressed to be asked or refused to join the study, and some could not be followed up, especially younger patients who had experienced negative consequences from their drinking. These exclusions mean the results may not be applicable to emergency patients across the board. A planned six-month follow-up should help establish whether the short-term effects reported in the featured study persist. On the other hand, control group patients underwent an assessment of their drinking so the results reflect the added value of providing feedback, not the full benefit of screening, assessment and feedback. Similarly the cost estimates represent the added costs of feedback, not the full costs, though these would still be lower than a screening-assessment-intervention package which featured face-to-face intervention.
commentary This study adds to other findings which show that screening for risky drinking and, if indicated, offering very brief advice reinforced by written material may be a worthwhile preventive intervention. Though not tested by the featured study, other studies provide no convincing case for more extended (if still brief) intervention, except perhaps for clearly dependent drinkers.
Patchy results in emergency departments have prompted attempts to identify why some brief interventions have worked but others have failed. As yet the evidence is insufficient to answer this question. In particular, it remains unclear whether a relatively elaborate, theory-based approach really is needed. One well designed US study, which managed to follow-up nearly all the patients it recruited, found that a sophisticated structured intervention was no more effective than one minute of straightforward advice at discharge that (among other things) the patient cut their drinking. Both interventions were conducted by emergency department staff.
Most recently and most convincingly for the UK, the non-superiority of longer interventions was the message of preliminary These findings are from factsheets and conference presentations in advance of peer-reviewed journal publication. findings from the emergency department arm of the SIPS project, funded by the Department of Health in 2006 to evaluate different ways of identifying risky drinkers through routine screening, and different forms of brief advice to help them cut back. It compared more extended advice or counselling against very brief face-to-face feedback (indicating that the patient was drinking "above safe levels, which may be harmful to you") accompanied by an alcohol advice booklet. Six and 12 months later the proportions of patients scoring as at least hazardous drinkers on the AUDIT questionnaire had fallen overall by nearly 11% and 16% respectively, but on this measure nor on the other main yardsticks (alcohol-related problems and health-related quality of life) had the longer and more sophisticated interventions significantly bettered the most basic.
The findings seem at odds with those from the best researched British emergency department programme at St Mary's hospital in London, which screens suspected heavy drinkers or patients with complaints linked to heavy drinking. In the relevant study, doctors explained to all positive screen patients that drinking was damaging their health, then patients were randomly allocated to be given only an alcohol advice booklet, or offered an appointment with an on-site health worker for counselling – similar to the SIPS trial's comparison between brief feedback and lifestyle counselling. But the findings were not similar; offering counselling was found to further significantly reduce return visits to the department and later drinking, the latter more cost-effectively than brief feedback.
One possibly critical difference is that at St Mary's the patients were typically very heavy drinkers and clearly dependent, averaging AUDIT scores three times those in SIPS. This too was the case in another UK study which found that an option similar to the SIPS counselling intervention led to much greater remission in dependence and drinking than assessment only.
Beyond the emergency department too, support is weak for extended intervention. Two UK studies of non-emergency hospital patients tested fully fledged brief interventions against a minimal intervention based on handing over an advice booklet with or without a warning about the patient's drinking. In the first, relative to assessment only, both interventions led patients to cut drinking by on average 2–3 UK units a day; nothing was gained from further counselling. In the second, neither intervention significantly improved on assessment only; all the groups reduced their drinking to roughly the same degree.
Internationally too, studies have usually found more extended brief interventions offer no advantage over briefer ones (1 2 3). A review of such interventions at GP practices found more extended interventions have led to only slight and statistically non-significant extra reductions in drinking.
Even if more is not always better, perhaps, as the featured study suggests, giving some advice rather than none is worthwhile. Previous studies have shown that just a few minutes counselling at-risk drinkers among emergency patients can reduce consumption and alcohol-related injuries, improve welfare, promote treatment uptake, and cut the future workload of emergency services. But there have also been negative findings, and the research record is fairly evenly balanced between these and more positive findings.
Perhaps most disappointing was the large-scale and important US ED SBIRT study at 14 emergency departments. It faced implementation barriers in attempting to use routine emergency staff for the interventions, and promising outcomes three months later had by six and twelve months nearly or entirely dissipated, leaving no statistically significant differences in alcohol consumption between intervention and control groups.
A recent synthesis of research on interventions conducted actually in the emergency department rather than after admission found that overall such interventions have not been shown to significantly reduce alcohol consumption, while impacts on drink-related problems have been variable. More positively, three studies did together indicate that six to 12 months after the interventions patients were half as likely as comparison patients to have suffered an alcohol-related injury, but all three were from the USA, and two involved only teenage patients whose drinking would have been illegal in that country. In all three the patients were known to have recently been drinking or had a history of drink problems rather than merely having tested as exceeding national drinking guidelines, underscoring the possibility also emerging from the featured study that when patients understand or have to admit that their illness or injury may be alcohol-induced, advice to cut back has a greater impact.
The UK alcohol strategy published in 2012 said government was awaiting the results of the SIPS project described above before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking, in the case of hospitals by employing alcohol liaison nurses. In general, all areas covered by the strategy are expected to implement guidance from the National Institute for Health and Clinical Excellence on prevention and treatment of drinking problems and associated quality standards and guidance for commissioners.
These documents' insistence that commissioners and managers of NHS-commissioned services "must" ensure staff have enough time and resources to carry out screening For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. and brief intervention Guidance explains that this can comprise either a short session of structured brief advice or a longer, more motivationally-based session (that is, an extended brief intervention). work effectively seems a tall order given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation and the need for specialist support – and this in services which had volunteered to participate in the studies. Implementation was most difficult in the emergency department arm of the study, in which only three of nine departments managed to implement the trial as intended. At the others, researchers helped out with the research-related tasks and the specialist alcohol worker had to help out with screening and interventions. Still the numbers screened seem to have been small, equivalent to about 12 per emergency department per week.
Where guidance seems at odds with SIPS and some other findings is in its backing for structured brief face-to-face advice covering the potential harm caused by the patient's drinking, reasons for changing including health and wellbeing benefits, barriers to change, and practical strategies, culminating in a set of goals. Subject to local conditions, also recommended is a more extended option – motivationally based counselling – for heavier but still probably non-dependent drinkers. Research as whole and in Britain offers no persuasive evidence that these relatively sophisticated face-to-face encounters are more effective than much briefer (and perhaps computerised or written) feedback/warnings.
The intervention tested in the featured study could effectively shift the intervention burden from clinical to administrative staff and reduce costs overall. What would remain for clinical staff is screening and the recording of the results. With no 'consequence' in terms of having to counsel positive screen patients, it is possible that not just intervention but screening rates would improve. There is at the moment no convincing reason to believe that such a procedure would be any less effective than more (for clinical staff) onerous procedures or ones which require the hiring of specialist staff to relieve the burden on emergency staff.
Last revised 24 September 2012. First uploaded 15 September 2012
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Psychology of Addictive Behaviors: 2012, in press.
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The contemporary recovery movement in addictions and the positive psychology movement in the broader field of psychological health have recently grown in prominence but almost entirely in parallel streams, yet the overlaps and possible synergies between them suggest that an integration could be a step forward in recovery from addiction.
Summary This review and conceptual analysis explores the overlaps and differences between (only briefly mentioned in this account) and research findings relating to two relatively new movements in psychology and addiction. Over the past decade, both fields independently recognised their work focused disproportionately on illness and pathology. Scholars in psychology called for the scientific study of human flourishing, which become the fast-growing subspecialty of positive psychology, while scholars in addictions research called for a new focus on recovery and sobriety, which became realised in the grassroots recovery movement.
Their similarities are in the emphasis on wellness rather than illness, and optimism that people can not only overcome pathology but develop more positive lives. However, they differ in important ways. The addiction recovery movement is a multifaceted grassroots effort led by people in recovery from substance use disorders, built on a recovery-oriented rather than pathology-oriented framework. Participants in the recovery movement work collectively to remove obstacles to treatment, support multiple paths to recovery, and make broader social systems more supportive of recovery lifestyles. The distinctive focus is primarily on macro-systemic change targeting policies, treatment systems, community resources, and social phenomena including stigma.
While the recovery movement has grass roots, positive psychology was sprouted in academic soil, but quickly spread to sections of the general population eager to improve their lives, lending it the character of a larger movement spreading beyond academia. Although positive psychology is concerned with positive organisations, its primary emphasis has been psychological change at the level of the individual. It recognises that there is more to mental health than the absence of mental illness – strengths, well-being, optimal functioning and flourishing. Flourishing individuals have been defined as "filled with emotional vitality ... [and] functioning positively in the private and social realms of their lives". Rather than seeking to overturn previous 'psychologies', positive psychology emphasises what it sees as some important but previously neglected perspectives.
Within this perspective, a positive intervention is defined as "an intervention, therapy, or activity primarily aimed at increasing positive feelings, positive behaviors, or positive cognitions, as opposed to ameliorating pathology or fixing negative thoughts or maladaptive behavior patterns". A subset of these interventions called 'positive activity interventions' can be completed without professional help. Two widely tested examples which may have potential in substance use disorders are the gratitude intervention called Three Good Things (write down three things that went well each day and their causes every night for a week) and the optimism intervention, Best Future Self (write down the realisation of all of your life dreams when in the future everything has gone as well as it possibly could).
So far limited work on contemporary recovery approaches to addictions suggests that new recovery institutions are filling a gap left by traditional professional treatment and mutual aid groups, and that continuing care interventions may offer benefits beyond those provided by acute care.
Some of the strongest findings (because they derive from randomised trials) related to the Oxford House recovery homes where individuals in recovery live, share expenses, and provide mutual abstinence-specific social support and other forms of concrete and emotional assistance. Residents themselves manage the business of the household and there are no limits on stays. For the randomised trial researchers recruited 150 adults from inpatient units in Illinois who agreed to be randomly allocated to usual care (the control group) or to apply to Oxford Houses. Compared to the control group, over the two-year follow-up period fewer Oxford House assignees were using alcohol or drugs or charged for a recent offence and more were employed. By the end fewer than half as many (31% v. 65%) were using alcohol or drugs, a third as many were in prison (3% v. 9%), and average earnings were substantially higher. All these differences were reported as statistically significant. Additionally, at two years 27% more Oxford House assignees had their own accommodation and nine more mothers had regained or retained custody of their children.
Another set of findings from randomised trials support the recovery movement's insistence that addiction should be treated as a chronic rather than acute disorder, implying long-lasting or open-ended support. Two trials have tested so-called 'recovery management checkups', quarterly meetings between counsellors and clients that take place consistently for two or three years – longer than traditional aftercare models – and treat each follow-up as an opportunity for intervention. After improvements were made, in the later trial checkup patients were more likely than controls to re-enter treatment if needed and received more treatment, attended more self-help meetings, achieved more days of abstinence, and lived in the community for shorter periods in a state where they needed, but did not receive, treatment. [Editor's note: these and other studies have recently been reviewed, the results of which led an expert panel to argue that extended and regular monitoring of patient progress was the key component of continuing care and one with the greatest evidence of effectiveness.]
How well do positive psychology interventions work? Beyond the addictions, a meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. of 51 randomised controlled studies of positive interventions amalgamated data from studies of healthy individuals and those suffering from depression. It found beneficial impacts in the form of moderate effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. for well-being and depression.
But a closer look at the research reveals that 'it works' would be too simple a verdict. In one body of work statistically significant differences were found when gratitude interventions were contrasted with 'hassles' conditions which ask participants to list things that irritate, annoy, or bother them, but not when they were compared to nothing intended to be an active intervention, except among groups more at risk than healthy populations. An emerging pattern suggests that those at a slight or great disadvantage, either because of illness, feeling bad, or being highly self-critical, seem to benefit more from a gratitude intervention than healthier individuals.
In respect of substance use, just one study (conducted in the UK) has applied positive psychology, in this case during group therapy of ten 14–20-year-olds attending an alcohol and drug treatment service for young people, comparing their results to a control group of ten not offered this extra intervention until later. The eight-week intervention promoted positive emotions, savouring, gratitude, optimism, strengths, relaxation, meditation, goal-setting and change, relationships, nutrition, physical activity, resilience, and growth. Compared to the controls, it led to greater increases in happiness, optimism, and positive emotions, and a much greater but (given small samples and highly variable levels of drinking) not statistically significant remission in symptoms of alcohol dependence.
Though these are the only findings specifically testing effectiveness, engagement in anti-relapse mutual aid and variables related to relapse to dependent substance use have been found to be related to key constructs in positive psychology. For example, among 126 former problem substance users abstinent for at least six months, the construct of 'hope' was strongly and positively correlated with other positive psychology constructs and with relapse-related variables including having a sense of purpose in life, social support, self-efficacy and psychiatric symptoms. The same was generally not the case however for 'spiritual transcendence' and 'flow' – the experience of losing oneself in pleasing, enjoyable activity.
In another study of 164 AA members sober for at least a year, the intensity of affiliation to AA was significantly associated with optimism, gratitude, purpose in life, and spirituality. However, this sample were relatively well-off and well educated and highly involved with AA.
These findings suggest that hope is possibly important in sustaining recovery, and are in line with findings that spiritual/religious practices are a mechanism via which AA affiliation affects drinking.
Despite tremendous growth in both positive psychology and the recovery culture, only the nine studies reviewed in this article have so far explicitly applied the discoveries of positive psychology to substance use, addiction treatment, and recovery, yet in other sectors these approaches have become prominent. The recovery movement has historically been an initiative for macro systemic change, while positive psychology has historically promoted micro interventions designed to create change at the level of the individual. Integrating the two can more comprehensively engage the spectrum of care necessary to adequately address addiction.
Thanks for their comments on this entry in draft to Amy Krentzman of the University of Michigan in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 17 October 2012. First uploaded 16 October 2012
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REVIEW 2006 My way or yours?
REVIEW 2011 Motivational interviewing for substance abuse
REVIEW 2005 The motivational hallo
Akhtar M., Boniwell I.
Groupwork: 2010, 20(3), p. 6–31.
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Conducted in England, this first study to test positive psychology approaches focused on strengths and wellbeing in the treatment of substance use problems found that a small group of young drinkers and drug users responded well, with substantial remission in alcohol dependence despite the non-substance focus of the group therapy.
Summary This study conducted in Bath is the first to test positive psychology approaches in the treatment of substance use problems.
As described in this review, positive psychology recognises that there is more to mental health than the absence of mental illness – strengths, well-being, optimal functioning and flourishing. Within this perspective, a positive intervention is defined as "an intervention, therapy, or activity primarily aimed at increasing positive feelings, positive behaviors, or positive cognitions, as opposed to ameliorating pathology or fixing negative thoughts or maladaptive behavior patterns".
Adolescent well-being has been high on the agenda of positive psychology, responding to the shift in mental health which has seen depression become a disorder of the early teenage years. Its co-founder has argued that building strengths such as optimism, future-mindedness and perseverance, acts as a buffer against mental illness and is more successful in the prevention of serious health problems than disease model approaches.
So far positive psychology has focused its interventions on general rather than specific adolescent populations. The featured study sought to advance knowledge by piloting a positive psychology group intervention to enhance well-being and reduce alcohol dependence among alcohol-misusing adolescents.
Weekly for eight weeks the intervention promoted positive emotions, savouring, gratitude, optimism, strengths, relaxation, meditation, goal-setting and change, relationships, nutrition, physical activity, resilience, and growth. Each session began with a gratitude exercise during which the clients appreciated the good things in their lives. In contrast to usual treatment, the focus was not on pathology, except in the fifth session which addressed alcohol misuse as the starting point for change. This session incorporated coaching techniques to set goals for the second half of the programme, so from then on each participant had individual coaching at the end of each session in order to report back on goal progress and identify next steps.
The intervention was applied during group therapy of ten 14–20-year-olds attending an alcohol and drug treatment service for young people in Bath, most of whom were not in education, employment or training. Their progress and outcomes were compared to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group of ten not offered this extra intervention until later. Allocation was not at random.
Interviews exploring well-being and substance use were recorded at the start of and on completion of the intervention (when clients were also asked about their experience of the programme), and six and twelve weeks later. Staff too were interviewed.
The accounts of the participants suggested that 'gratitude' (recalling things that went well each day and their causes) was arguably the most successful exercise. It made the biggest impact on happiness, was the most widely used after the intervention, and one of the most frequently experienced positive emotions. The concept of appreciation for the good things in life was previously alien to the group, whose collective mindset was one of deprivation.
Increased confidence was the most noticeable development at the final assessment, probably aided most by the session on strengths. Identifying strengths helped the participants develop a more positive view of themselves and to have the confidence that they could be themselves rather than put on a front or play up to the tabloid label of 'feral' youth.
Development of a future goal orientation was one of the main outcomes of the study, aided by coaching in 'life planning' – identifying self-generated goals and breaking these down in to smaller steps. Goal-setting also facilitated the shift from pessimism to optimism about the future. Over half the group achieved goals which ranged from attending school to handing in assignments, bidding for accommodation and improving relationships.
Most of the group had been heavy users of both alcohol and drugs. For most drinking and cannabis use went from being a full-time activity to an evening or weekend one. Many came to see alcohol and drugs as a block to well-being rather than a source of happiness. The service manager reported that there was no longer the trail of crisis and chaos that accompanies heavy drinking, and that for many, substance misuse was no longer a cause for concern.
These impressions were supplemented by questionnaire assessments which could be compared with those of the control group at the start and end of the intervention phase. Compared to the controls, the positive psychology intervention led to greater increases in happiness, optimism, and positive emotions, and a much greater but (perhaps due to small sample size and the extreme variation in severity) not statistically significant extra remission in symptoms of alcohol dependence. However, within the positive psychology group reductions in typical alcohol dependence scores were substantial and statistically significant, halving from the start to the end of the intervention phase and then falling to a third of the original level. All these improvements in the positive psychology group were sustained to the last follow-up.
Both qualitative and quantitative findings suggest that the intervention was related to a significant increase in well-being and a significant decline in drinking. Gratitude seemed to have had the strongest effect of all the tactics (especially among the girls), supporting other findings that 'counting blessings' is associated with optimism, life satisfaction and fewer bad feelings. Such was its impact that it is recommended that it should be a cornerstone of future positive psychology programmes for disaffected youth, who tend towards a mindset of deprivation.
The happiness experienced by the group developed from 'feeling good' to being based more on things going well and expressed through increased confidence – more related to realising one's potential than hedonism, paralleling a more long-term perspective on life. Identifying strengths had a positive influence on the participants, most of whom had been excluded from mainstream education. Eight out of the 10 re-engaged with education in the wake of the intervention.
Typical alcohol dependence scores fell by two thirds, raising the question of why this was achieved after an intervention which largely 'parked' drinking problems. Two factors seemed influential. As the young people began to feel happier, they expressed less need to drink in order to escape difficulty. Secondly, as they developed a future goal orientation, they began to see their alcohol habits as a hindrance to realising their ambitions.
Experience of a group-based intervention also played a role in increased positivity. Friendships formed and the group were mutually supportive. Participants became more sociable, perhaps due to feeling happier and less depressed.
commentary As the researchers comment, this is very much a pilot study of a small sample at single service, not randomly allocated to intervention and control groups, so possibly differing in ways which affected the outcomes regardless of the intervention. Also the researcher was co-facilitator of the intervention, increasing the risk that the young clients, who could not be assured that that their views would be anonymised, tended to respond at the follow-ups in ways which met her expectations, and that
In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers.
1. See articles at the following web addresses:
to the intervention resulted in unintended bias in the results and observations. The results are notable as a first test of the approach, but before being relied on require confirmation in a more rigorous study.
That said, the results 'make sense' in that finding the good and the positive in and for youngsters seen negatively by themselves and by society is likely to be transformational, an extension of the 'positive regard' conveyed by the therapist towards their client, now widely recognised as important to the success of psychotherapy and counselling. However, the study was not capable of disentangling what led to greater improvements from the intervention. Candidates are the positive psychology techniques, influence of the therapists, experience of being in the group, extra attention, greater expectations of getting better on the part of both therapists and clients, individual coaching, or the feeling of being singled out for something special and experimental.
Thanks for their comments on this entry in draft to Miriam Akhtar, positive psychology consultant, trainer, coach and author. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 20 October 2012. First uploaded 16 October 2012
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