Changing Addictive Behavior: Bridging Clinical and Public Health Strategies,

In 1990, the Institute of Medicine of the National Academy of Sciences published a report entitled Broadening the Base of Treatment for Alcohol Problems(1). The report, prepared by a committee chaired by Dr. Frederick Glaser, made sweeping recommendations for expansion of the availability of a variety of treatments for alcohol problems. Noting that the treatments currently favored were appropriate for patients with alcohol dependence, the report pointed out that in the general population there were a far greater number of people either at risk for alcohol problems or experiencing mild to moderate problems. For these nondependent drinkers, modification of the quantity, frequency, and setting of their alcohol use might be appropriate goals. The report stressed that although the severely dependent drinkers produced the highest rates of alcohol-related problems per individual, on an aggregate societal basis the at-risk and nondependent problem drinker produced a large number of highly significant problems and constituted a largely unaddressed challenge. The committee recommended adopting a public health approach to this problem.

When the National Academy’s committee was meeting, in the last years of the decade of the 1980s, the growth of the private for-profit chemical dependency treatment system was at its peak, fueled by increasing health insurance coverage for alcoholism treatment. As a result, a two-tiered system had developed consisting of separate publicly funded and privately financed treatment. The outlook for continued growth of both seemed rosy, and the development of a new emphasis on the less severely affected seemed appropriate.

It turned out to be quite difficult for the field to respond to this challenge, however, because the health care system itself began to change rapidly and began to contract. Managed care was introduced into both private and public systems as a cost-cutting measure, and many programs closed. Access to care, quality, and cost became overriding concerns, and expansion became an unrealistic objective to many.

In Changing Addictive Behavior: Bridging Clinical and Public Health Strategies, the editors attempt to respond to the Institute of Medicine’s challenge in the new managed care setting. The foreword, written by Dr. Glaser, compares the contrasting ancient Greek philosophies of Hygieia and Asclepius to the differences between public health and clinical medicine approaches to addictive disorders. As the title of the book indicates, the editors are making an attempt to bridge the gap. The first seven chapters are devoted to research findings and concepts, and chapters 8 to 13 discuss clinical applications. Unfortunately, the number of current applications discussed is small and concentrated on smoking cessation programming and brief intervention in primary care medical settings. There is a greater stress on possible approaches that might be applied and principles of such programming.

The strengths of this volume are the well-written theoretical chapters on studying access to and need for treatment, influences on the process of help-seeking, the concept of motivation for change, the transtheoretical model of stages of change, and the clinical applications chapters about brief intervention, nicotine dependence treatment in a public health framework, and “stepped care” for alcohol problems.

The book has weaknesses as well, unfortunately. The chapters are uneven and often repetitious. For example, although an entire chapter is devoted to the criticism of Project MATCH (a large-scale clinical trial financed by the National Institute on Alcohol and Alcohol Abuse), it is described and criticized in several other chapters as well. It also becomes clear, through this repetition, who the bad guy is, namely, the 12-step/disease model treatment. This treatment is repeatedly criticized as stigmatizing, rigid, and, in some places, ineffective, in contrast to harm reduction, which gets rave reviews. The characterization of the disease model is often simplistic and distorted. For example, in a table on page 116, Tucker and King characterize the 12-step/disease model as maintaining that “largely unalterable biological factors are the main controlling variables of addiction,” in contrast to research that finds “changeable environmental contexts influence the initiation, maintenance and resolution of addictive behaviors.” Another table, on page 350, contrasts physical disease and mental health paradigms, noting that the physical disease approach involves 1) treating biological causes 2) in inpatient medical settings, 3) after a brief history, physical examination, and detoxification, 4) at relatively high cost, and 5) with limited follow-up care. I do not believe that these characterizations accurately describe either current addiction treatment based on a biopsychosocial understanding of addictive behaviors or the mutual-help, 12-step philosophy. It is also rather surprising to read that the disease concept is stigmatizing, since one of its great advantages has always been relief from the stigma that conceptualizes addiction as a category of immorality.

Perhaps the greatest problem with the book is its use of language. The terms “use,” “abuse,” “misuse,” “addiction,” and “dependence” are often employed very loosely. They are sometimes defined and sometimes not. It is often impossible to understand what kinds of behavior are meant by “addictive.”

All in all, the book is uneven, but it has some interesting and useful information. As a response to the Institute of Medicine challenge, it rates a mixed review.