Brief intervention, three decades on

Transcription

1 Overview Per Nilsen Eileen Kaner Thomas F. Babor Brief intervention, three decades on An overview of research findings and strategies for more widespread implementation Introduction The last three decades have seen a paradigm shift with regard to alcohol treatment and prevention, as the disease model of alcoholism has been expanded with the concept of a continuum of use that encompasses a much greater proportion of the population. It has been recognised that the majority of alcoholrelated harm on a population level is attributable to the large group of hazardous and harmful drinkers rather than individuals with severe alcohol-related problems or alcohol dependence. The result has been a shift in attention from treating solely dependent drinkers at one end of the continuum to secondary prevention efforts targeting individuals at risk of alcohol-related harm (Botelho & Richmond 1996; Babor & Higgins-Biddle 2000). A B S T R A C T P. Nilsen & E. Kaner & T. F. Babor: Brief intervention, three decades on. An overview of research findings and strategies for more widespread implementation This paper provides an overview of brief intervention (BI) research to date and discusses future research needs as well as strategies for more widespread use of BI. Research has firmly established that significant reductions in drinking can be achieved by BI in a variety of health care settings. Despite convincing evidence, however, diffusion of BI in routine health care has been slow. Alcohol is a complex subject since it is often used moderately, without sideeffects, and in a socially acceptable way. Although research on BI has accumulated rapidly during the last three decades, many important research challenges and development work remain before BI is widely implemented in routine health care. Keywords BI, Brief intervention, alcohol, history, implementation, overview This study was supported by grants from the Swedish National Rescue Services Agency. Dr. Babor s contributions to this article were supported in part by a grant from the US National Institute on Alcohol Abuse and Alcoholism (P60 AA003510). Sincere thanks to Preben Bendtsen, Cheryl Cherpitel, and Kaija Seppä for feedback and comments on earlier drafts of this paper. NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

2 The shift towards an alcohol risk continuum has led to an increased expectation for health professionals to become more involved in identifying and intervening with drinkers whose alcohol consumption exceeds recommended levels and therefore experience an increased risk of physical, psychological, and social harm. In the past, health care professionals role was to identify persons with alcohol dependence and refer them for specialized treatment. Today, these professionals are expected to become more involved in identifying and intervening with drinkers who are not seeking help for alcohol-related problems but who may attend general health care settings for reasons related to their drinking (Fleming & Graham 2001). Brief intervention (BI) emerged in the 1980s as a strategy to provide early intervention, before or soon after the onset of alcohol-related problems, with the aim of moderating drinking rather than promoting abstinence (Babor et al. 2007). The origins of BI can be traced to late 1970s work by Miller and his research group and Edwards and colleagues who had shown that less intensive was often as effective as more intensive treatment (Kaner et al. 2008). Another influence was a study by Russell et al. (1979) that showed that simple advice to patients to stop smoking produced small but significant rates of smoking cessation. This paper provides an overview of BI research to date, discussing results from three research areas: evaluations of BI efficacy and effectiveness, studies on barriers to addressing alcohol issues and providing BI in routine health care, and studies concerning various strategies to achieve wider dissemination and implementation of BI in health care. Future research needs are reviewed and strategies for more widespread use of BI are discussed. Defining BI BI is a time-limited, patient-centred approach that focuses on changing behaviour. BI is not unique to the alcohol field. In fact, these advice and counselling strategies are widely used by health professionals for a number of other health-related behaviours, including changing dietary habits, reducing weight, smoking cessation, and reducing cholesterol levels (Fleming & Graham 2001). In general health care settings, BI refers to any therapeutic or preventive consultation of short duration undertaken by a health professional who is not usually a specialist in addiction treatment (Aalto et al. 2001). However, the BI term has been used flexibly in the alcohol literature to encompass a wide range of activity in addressing alcohol-related risk and misuse, from a single 5-minute session of simple advice delivered by a generalist health care provider (e.g. a physician or nurse in primary health care), through to multiple sessions of counselling, accompanied by repeated follow-ups delivered in specialist settings (Kaner et al. 2007). Hence, BI should not be regarded as a homogeneous entity, but as a family of interventions varying in duration, content, targets of intervention, and providers responsible for their delivery (Smith et al. 2003). An important distinction should be made between opportunistic and specialist BI. Opportunistic BIs are delivered to people who are not seeking treatment for a problem with alcohol. In those circumstances, inquiring about alcohol consumption can be seen as the first step of a BI. 454 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

3 In contrast, specialist BIs are delivered in specialist alcohol treatment settings where people have attended to seek treatment for an alcohol problem. In general, BIs for non-treatment-seeking population tend to be shorter, less structured, and less theoretically based than those applied in specialist settings (Heather 1996). While the definition of BI varies across studies and settings, a number of common elements can be identified. Some studies have used the FRAMES components developed by Miller and Sanchez as a guide for the intervention: Feedback (on the patient s risk for alcohol-related problems); Responsibility (for change lying with the individual); Advice (concerning reduction or direction to change); Menu (of change options); Empathy (a warm, reflective, and understanding approach); and Self-efficacy (encouragement of optimism about achieving change) (Bien et al. 1993). Other studies have stressed the following BI components: assessment; direct feedback; negotiating and goal-setting; behavioural modification techniques; self-help manual; and follow-up and reinforcement (Flemming & Graham 2001). As yet there is no agreement about a general theoretical perspective that would guide the selection and use of these ingredients, although there have been attempts to interpret them in the context of motivational enhancement, cognitive-behavioral skills training, and trans-theoretical models of behavior change (Barry 1999). The BI evidence base Over the last 25 years, over 50 randomised, controlled trials of BIs delivered to non-dependent, non-treatment-seeking patients in various health care settings have been conducted. Most of the research to date has been undertaken in English-speaking countries (UK, USA, Canada, Australia), Nordic countries (Sweden, Norway, Denmark, Finland), and some Continental countries in Europe (Spain, France, and Germany). The cumulative evidence base regarding BI efficacy and effectiveness has been documented in 15 systematic reviews and meta-analyses of BI study data since 1993 (Bien et al. 1993; Kahan et al. 1995; US Preventive Services Task Force 1996; Wilk et al. 1997; Ashenden et al. 1997; Poikolainen 1999; Moyer et al. 2002; D Onofrio & Degutis 2002; Beich et al. 2003; Salaspuro 2003; Ballesteros et al. 2004; Whitlock et al. 2004; Bertholet et al. 2005; Kaner et al. 2007; Nilsen et al. 2007). It has been argued that early BI studies tended to be carried out under tightly controlled efficacy conditions designed to optimize internal validity, i.e. establishing that the effects were caused by the intervention. While establishing efficacy under these conditions is an important first step before more widespread implementation of new interventions can occur, the enhanced internal validity is often gained at the expense of external validity, which makes it hard to generalize findings across different types of patients and settings (Drummond 2002). Some of the early studies raised questions as to their selected study populations and rigid protocols that would be difficult to implement in everyday care settings (Salaspuro 2003). Another problem concerned patients lost to follow-up. Since patients who dropped out during the follow-up might differ significantly from those who stay in a study, basing estimates of effects only on those who can be followed up could bias the NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 results considerably (Edwards & Rollnick 1997). More recent BI research has seen an increased emphasis on evaluations conducted under more realistic conditions, using more heterogeneous populations and less support for health professionals in order to provide evidence of BI effectiveness in the real world. In such studies, screening for hazardous and harmful drinkers has been incorporated into routine practice and BI is offered immediately upon a positive case being identified (Heather 2002; Babor et al. 2006). While it was speculated that BIs provided in more naturalistic conditions would prove less effective than those delivered under the most optimum research conditions possible, Kaner et al. (2007) demonstrated in a Cochrane review that there was no significant difference in outcomes (reduction in weekly alcohol consumption) between these study types. Most of the BI studies have been performed in primary health care settings. In comparison, relatively few emergency care studies have been conducted. The BI evidence in emergency department and trauma centre settings is more mixed than in primary health care settings. Bernstein and Bernstein observed in 2008 that research in this setting is still in its early stages and that researchers are running to catch up with primary health care research. It has been speculated that the difficulties of achieving positive results in emergency care settings may be due to the often crowded and hectic environment, which may cause interruption of interventions (Nilsen et al. 2007). Furthermore, most BI emergency care studies have focused on injury patients (who comprise 30 40% of the total emergency care population), with an over-representation of younger men with minor injuries. This patient category is likely to be less inclined to reduce its alcohol consumption than the older populations of most primary health care studies (Daeppen et al. 2007). The efficacy and effectiveness of BI have also been demonstrated in hospital settings (Emmen et al. 2004) and among specific patient categories such as students (Marlatt et al. 1998) and pregnant women (O Connor & Whaley 2007). Moreover, the cost-effectiveness of providing BI has been reported (Fleming et al. 2000; Fleming et al. 2002). Despite a general preponderance of positive findings, many BI studies have reported significant reductions in control group drinking measures that are comparable to those of the BI group. Some of these studies have had inadequate sample size to detect significant difference between the groups, but in other cases unexpected improvement in control groups can not be explained by low statistical power. It has been suggested that historical effects may yield alcohol consumption reductions because people naturally change their drinking behaviour over time due to health, family, work or cultural factors. Regression-to-the-mean effects are often offered as an explanation, i.e. extreme scores on any measure at one point in time will, for purely statistical reasons, probably have less extreme scores the next time they are tested (Stout 2007; Fleming & Graham 2001). Another reason could be Hawthorne effects, referring to unintended reactivity to study conditions by study participants, with a resulting impact upon perceived socially desirable behaviour (Adair 1984). Thus, awareness that one s drinking is be- 456 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 ing monitored may induce motivational effects and actual behaviour change. Many BI studies have involved fairly comprehensive assessment procedures for both intervention and control groups. This has led to speculation as to whether screening itself may constitute a sort of an intervention, which could explain why control group participants also reduce their alcohol consumption. It seems likely that alcohol screening provokes contemplation about drinking and makes the patient aware of his or her alcohol intake in a way that might not occur otherwise. In the first study to specifically examine the direct effects of screening, McCambridge and Day (2007) showed that being screened with AUDIT with no subsequent BI or other intervention led to reduced self-reported hazardous drinking, with the effect sizes being similar to the known effects of BIs. They argued that this was a remarkable demonstration of the potency of alcohol screening as an intervention in its own right. While there are remaining research challenges, the scientific literature has provided a solid evidence base that supports the efficacy and effectiveness (the terms are often used interchangeably in studies) of BI at reducing hazardous and harmful alcohol consumption in non-dependent, non-treatment-seeking patients. Research over the past three decades has firmly established that significant reductions in drinking and related risks can be achieved by BIs in a variety of settings. Barriers to diffusion of BI Despite the convincing evidence for the efficacy and effectiveness of BI, diffusion of such interventions in routine health care has been slow. Diffusion refers to the spread of ideas, concepts and practices within a social system, typically via communication and influence (Greenhalgh et al. 2005). Several studies in the 1980s and 1990s documented poor uptake and utilization of BI among health professionals in primary health care (Anderson 1985; Clement 1986; Volk et al. 1996). Patients themselves have reported that they are rarely asked about alcohol issues, even when they are hazardous or harmful drinkers (Aalto et al. 2002). Research interest in identifying barriers in general health care settings increased markedly in the 1990s, as it was becoming increasingly evident that diffusion of BI into regular practice was not going to occur at the pace anticipated by many researchers. This research was considered important in order to design and implement interventions (typically referred to clinical or implementation interventions) to address the barriers in order to promote BI activity. Factors that affect providers reluctance to inquire about alcohol and/or provide BI have been studied in numerous quantitative surveys and qualitative interviews. Shaw and colleagues addressed this issue as early as 1978 in the UK governmentfunded Maudsley Alcohol Pilot Project, for which they interviewed and surveyed a large number of health professionals. They found that general practitioners suffered from what they termed role insecurity. This insecurity stemmed from the fact that they felt that they lacked necessary skills and knowledge to recognize and respond to drinkers (poor role adequacy), uncertainty as to whether or how far drinking problems came within their responsibilities (poor role legitimacy), and inadequate NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

6 resources, either from training or from their work situation (poor role support) (Shaw et al. 1978). The continued relevance of the barriers identified by Shaw and colleagues in their seminal study has been confirmed in most subsequent studies. However, studies have also elaborated on their initial work and described additional barriers. The majority of this research has concerned the attitudes of physicians in primary health care settings although a few studies have also involved nurses. As with BI efficacy and effectiveness evaluations, the majority of the research has taken place in Englishspeaking countries (UK, USA, Canada, Australia) and Nordic countries (Denmark, Sweden, and Finland). Overall, findings from these studies have been very consistent, with most studies reporting similar barriers to the discussion of alcohol in routine consultations and the provision of BI for non-treatment seeking patients. The barriers are not mutually exclusive, as considerable overlap between different factors may exist. Motivation to address alcohol issues and/or conduct BI can be viewed as a dynamic product of the interaction of characteristics of the health professionals, their relationship with the patients, and the setting and wider context in which this activity occurs. Concerning characteristics of the health professionals, many studies have revealed that they are reticent about tackling an issue with widespread social acceptance (Cartwright 1980; Thom & Tellez 1986; Roche et al. 1991; Weller et al. 1992; Rush et al. 1995; Johansson et al. 2002; Hutchings et al. 2006). Alcohol consumption is a complex subject, since it is often used moderately, without side-effects, and in a socially acceptable way. Health professionals disagree about the point of which drinking becomes a problem. Most health professionals have received little or no preparation for alcohol-preventive work, either in their undergraduate education or continuing professional education (Anderson 1985; Clement 1986; Roche et al. 1991; Beich et al. 2002; Anderson et al. 2003) and they do not feel confident in their abilities to intervene with alcohol problems (Cartwright 1980; Bruce & Burnett 1991; Rush et al. 1995; Wechsler et al. 1996; Kaner et al. 1999; Lock et al. 2002). Moreover, health professionals are sceptical as to the expected effectiveness of counselling in alcohol issues (Thom & Tellez 1986; Bruce & Burnett 1991; Weller et al. 1992; Kaner et al. 1999; Aira et al. 2003). The relationship with the patient also impacts on the health professionals willingness to address alcohol issues. Due to the perceived sensitivity of the alcohol issues, health professionals generally find it difficult to raise the issue of alcohol drinking with patients who are not seeking help for alcohol-related problems (Rush et al. 1995; Lock et al. 2002; Aira et al. 2003; Hutchings et al. 2006). Many are afraid of provoking negative reactions and losing rapport with patients (Weller et al. 1992; Lock et al. 2002; Aira et al. 2003). With regard to situational and contextual factors, a common finding is that perceived lack of time for overburdened health professionals constitutes a considerable barrier to their work with alcohol issues (Bruce & Burnett 1991; Rush et al. 1995; Kaner et al. 1999; Beich et al. 2002). Concern has also been expressed about inadequate materials for intervening with alcohol problems, including alcohol ques- 458 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

7 tionnaires and self-help booklets, and a lack of structured office system to facilitate screening and interventions (Aalto et al. 2001; Aira et al. 2003). While financial disincentives have often been described as being less of an obstacle than most other factors, there are also studies (e.g. Hutchings et al. 2006; Rapley et al. 2006) that show that poor reimbursement for alcohol-preventive work constitutes a barrier. Several organizational factors also play an important role, including the type of leadership provided and the stability of the clinic environment (Babor et al. 2005). Clinical interventions for increased dissemination and implementation of BI Research findings concerning barriers to BI diffusion have been used to design and implement interventions intended to achieve wider dissemination and implementation of BI among health professionals. While dissemination is often used interchangeably with the term diffusion, the former is a planned and active process whereas the latter is an essentially passive process. Implementation and dissemination should also be distinguished; dissemination is the process of spreading information to create awareness and increased knowledge among defined target groups, whereas implementation is concerned with actual usage in practice, i.e. achieving behaviour change (Greenhalgh et al. 2005). The results of clinical interventions for increased BI activity in primary health care settings have been synthesized in two systematic reviews. In a systematic review and meta-analysis, Anderson and colleagues (2004) examined 15 studies describing educational and office-based interventions in terms of impact on screening and BI-delivery rates. They found that the interventions increased the screening and BI activity by 8 18% over the performance of the comparison groups (a less intensive intervention or no intervention at all). Educational programmes that were alcohol-specific (rather than dealing with alcohol as one of several lifestyle issues) and had multiple components were most effective. No differences were found between educational interventions and office-based interventions. The authors concluded that it seems possible to increase the engagement of general practitioners in screening and giving advice for hazardous and harmful alcohol consumption (Anderson et al. 2004). In a systematic review, Nilsen et al. (2006) analysed 11 studies that evaluated the effects on utilization of screening materials (e.g. AUDIT questionnaire, provider advice, and patient booklet) and activity in screening and BI following clinical interventions of varying intensity, from merely sending screening materials to providing materials, education, and subsequent support for the health professionals. They found that the overall effectiveness was rather modest. BI activity increased with the intensity of the intervention. Nilsen and colleagues were more cautious than Anderson et al. (2004) in their conclusions, noting that few authors of the reviewed studies expressed much optimism about successfully implementing BI without substantial training and ongoing support for the health professionals. The alcohol field is far from unique in its difficulties of achieving more widespread implementation of BI in routine practice. Indeed, a consistent finding in NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

8 health systems research is that the transfer of research findings into practice is often unpredictable and complex. Evidence derived from research is usually only one component of clinical decision-making. Research has demonstrated repeatedly that there are many barriers to translating research knowledge into practice. This lack of transfer has been termed the knowledge transfer gap and is considered by many to be one of the important challenges facing modern medicine (Graham et al. 2007). Future challenges Research on BI has come a long way in the last three decades. Tremendous progress has been made in terms of establishing a scientifically sound evidence base for the efficacy and effectiveness of BI in various settings. This intervention research has been driven by the question does it work?, initially under more ideal efficacy circumstances, but increasingly in more realistic effectiveness contexts. The challenge for future BI research is to further explore the mechanisms of change of these interventions for improved understanding of what makes BI work? and under what circumstances and for whom the best results can be expected. More research is needed into how screening and assessment reactivity (and not just the BI part ) may promote behaviour change. The continued isolation of research and practice on alcohol BI from the context of wider behavioural risk factors is another limitation of current research approaches. Many persons with at-risk drinking also have other behavioural risk factors, such as smoking and illicit drug use. Design, implementation, and evaluation of combined interventions focusing on inter-related behavioural risk clusters are needed to advance our understanding of how best to approach the multiple health risks that characterize a given population. It is also important to broaden BI research geographically. Much of this research has been conducted in a few select countries, with many trials focusing on interventions for middle-aged men in primary health care settings. Hence, there is a need for more BI trials in the developing world, studies in other settings than primary health care, and increased focus on BIs delivered to women and various minority groups. With regard to BI diffusion research, the majority of studies undertaken hitherto have taken the form of cross-sectional observational studies. There is a paucity of longitudinal studies to allow for examination of causality between various factors or analysis of the extent to which health professionals alcohol-related knowledge, attitudes, and practice may change over time. A few studies (e.g. Wechsler et al. 1996; Kaner et al. 1999) have suggested that there have been long-term improvements regarding the proportion of health professionals who perceive that they possess adequate skills, believe that alcohol counselling is important, do not feel hindered by interpersonal factors, and are optimistic about the potential for modifying alcohol use. Still, research on barriers to diffusion of BI seems to have reached a point where additional studies are likely to provide diminishing returns in terms of advancing the understanding of how or why BI is not more widely implemented in routine health care practice. Further research is needed on clinical interventions for increased BI activity. Re- 460 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

9 search in many fields has shown that there are no magic bullets for achieving health professional behaviour change; a range of clinical interventions can lead to behaviour change, but no single intervention is always effective for changing behaviour. Multifaceted clinical interventions tend to be more effective than single interventions because they address multiple barriers to implementation (Babor & Higgins-Biddle 2000; Anderson et al. 2004; Nilsen et al. 2006). Passive approaches such as mailed educational materials or attending lectures are generally ineffective and are unlikely to result in behaviour change when used alone. However, passive approaches represent the most common strategy adopted by researchers, professional bodies, and health care organisations. Active approaches are more likely to be effective but can also be expected to be more costly (Bero et al. 1998; Grimshaw et al. 2004). The majority of BI research has concerned physicians. However, nurses and other professions may be required to take a more active role in discussing alcohol issues with patients and providing BI in the future. Studies in the UK and Sweden (Deehan et al. 1998; Lock et al. 2002; Johansson et al. 2002) have suggested that nurses are an under-utilised resource since they may be more favourably disposed to preventive work in general and have a more holistic perspective on patients than physicians, with more time to spend with patients. Additionally, they are perceived as less formal than physicians. A generic lifestyle worker has also been discussed, i.e. someone trained in behaviour change techniques and dealing with multiple lifestyle issues, including smoking and diet as well as alcohol (Hutchings et al. 2006). Although it is ultimately the individual who decides whether or not to address alcohol with a patient or conduct a BI, it is important to systematically explore implementation models that do not make the individual health professional the centre of BI. It is important to account for both the inner organisational context in which alcohol-preventive work takes place, e.g. in terms of organisational policies, management support, and resource constraints, and the outer context that impacts on behaviour through the nature of financial arrangements, regulations of professions, broader policies and legislation, as well as the general public s awareness, attitudes, knowledge, and norms associated with alcohol issues. Some of the BI barriers that have been identified are relatively simple to address, such as disseminating information about the evidence in favour of BI and the availability of screening and BI materials. There is clearly a need for more and/or better education and training in alcohol issues. Generally effective continuing professional educational strategies include educational outreach, reminders, and interactive educational meetings, e.g. health professionals participation in workshops that include discussion or practice (Davis et al. 1995). However, it is also important to recognize that many health professionals already integrate discussions about alcohol into their everyday practice even though they may not refer to this as delivering a BI. These may be unstructured fragments of feedback on risk, advice on behaviour change, and target-setting for risk reduction (May et al. 2006). Hence, BI implementation efforts may benefit from less focus on attempts at introducing NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

10 new skills and more emphasis on enabling health professionals to build on skills they already have and use in practice. Factors such as time restrictions and inadequate reimbursement for alcoholpreventive work may be less amenable to short-term change. Studies on the impact of economic incentives on health professionals preventive care delivery have suggested that small rewards will not motivate physicians to change their routines (Town et al. 2005). However, pay-for-performance incentives have shown to be effective in increasing the delivery of smoking cessation advice given by primary health care physicians (Millett et al. 2007). Unquestionably, financial incentives affect behaviour and instead of asking can financial incentives result in more preventive activity? it may be more relevant to inquire how large an incentive does it take to change behaviour?. Health care professionals generally face time barriers to providing preventive services because most health care systems are focused on the management of acute illness and chronic health conditions (Glasgow et al. 2004). Still, the question is whether lack of time for alcohol-preventive work should be taken at face value. As pointed out by Aira et al. (2003), Why do we not have any barriers to examining diabetic patients or to follow-up of high blood pressure, even if it takes a lot of time? It would appear that priorities for screening particular illness conditions are based on health professionals knowledge, existence of tools, and their perceptions of patient requests. The use of computer-generated BI offers a potential means of minimising time restraints. There is a growing body of evidence supporting the effectiveness of computer-generated advice for many health behaviours, including drinking, smoking, diet, obesity, and physical activity (Nilsen et al. 2008). Computerized concepts have also been favourably evaluated in terms of feasibility, including health care providers acceptability of such approaches and patients willingness to participate in and satisfaction with computer-based interventions (MacMillan 1999; Rhodes et al. 2001; Gregor et al. 2003; Karlsson et al. 2005; Bendtsen et al. 2007). Although research on BI has accumulated rapidly during the last three decades, important research challenges and development work remain before BI is widely implemented in routine health care and is considered an integral part of mainstream preventive medicine and public health. However, the future of BI will depend not only on the available science base; more research alone will not be sufficient. Researchers have been the main agents of change in the move toward viewing alcohol risk in terms of a continuum and applying a population approach. However, it is important to recognize that the general public does not necessarily view alcohol problems and their solutions this way, which influences the feasibility and acceptability of providing BI in routine health care. Ultimately, a broad, all-encompassing systems approach involving not just researchers but also government agencies, health policy-makers, health care organisations, consumers, and the media is needed to build wider support for BI through increased public awareness of recommended drinking levels and modified public attitudes towards alcohol problems and alcohol-preventive work that focus on 462 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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