Dr. John Helzer is a professor in the Department of Psychiatry in UVM’s College of Medicine. In addition to his recent research into treatment methods for alcohol abuse, Helzer was part of a group of five psychiatrists who wrote the diagnostic criteria used internationally to define alcoholism. He is associate editor of Journal of Studies on Alcohol and an editorial board member of American Journal of Drug and Alcohol Abuse.

 

Much of your recent research deals with studying problem drinking/alcoholism. Could you tell me more about the particular focus and approach of this work?

My past alcohol work has mainly been in epidemiology, which has involved looking at drinking in the general population. My interest in this area began when I was asked to sit on a National Institutes of Health review committee considering treatment grant applications. Working as a member of that committee for a couple of years exposed me to a great deal of the treatment research and researchers leading the way on questions in this area.

The work I’m doing now explores a new methodology that has never been applied as a treatment device. In fact, it’s hardly been used in medicine at all. The pioneering work in using this technology was led by colleagues I’ve worked with at the Vermont Alcohol Research Center, which has been affiliated with UVM and includes a number of researchers who are based at the university.

The technology is called interactive voice response, or IVR. It is the sort of technology that you’ll encounter if you call a corporation and you get a recorded voice that says, “If you want this office, punch one, and so on.” In some cases it can be a technology that can be used to kind of stall and stonewall.

But it’s also a technology that can lend itself very nicely to other uses. At the Vermont Alcohol Research Center it’s used as a device for having people report their alcohol consumption on a daily basis, information that’s been quite difficult to gather in the past.

This is very useful information for a number of reasons, but it’s just not very accurate when it isn’t gathered daily. So we developed scripts that participants in the study could follow. They would call us on the telephone, the computer would ask the questions, they would punch in the answers with the telephone keypad, and it would all be automated. It would enable us to get information about how much alcohol people drank in the previous day, how many cigarettes they smoked, stress levels, depression levels, where they drank, etc. We could use this not only to track drinking fairly precisely over time, but also to look for correlations between mood and drinking, stress and drinking, or anger and drinking. It would allow us to get a better handle on some of the things that were, quite literally, “driving people to drink.”

Were you confident from the outset that this method of gathering information would be effective?

No, not at all. We had no idea if this would work, which is why we undertook the pilot studies here. This research started in the early 1990s, and gradually growing more sophisticated to the point that we followed thirty-three subjects over a two-year period. By using a behavioral system of rewards designed by Dr. John Searles, people received bonus points that built toward cash payments when they were faithful about checking in with their information. From that group of thirty-three, we got 96 percent of the calls over the two years, which is pretty amazing.

Are people’s responses different given that they’re talking to a computer rather than a person?

Absolutely. There is good evidence that they’re more candid and less self-conscious. People will report things that they would not report to another person even over the telephone, and they even report things that they would not report on a questionnaire.

Is this research at a point where you can say what light it has shed on alcohol abuse?

We’re just in the process now of doing those analyses. We have a sufficient amount of information to begin looking at the factors that promote drinking or tend to protect against it. We’ll also be able to look at factors like mood states that may be responsible for drinking on a daily basis. There’s a lot of research about the association between depression and drinking, stress and drinking and so forth but almost none of that is on a day-to-day basis.

What’s the next step you hope to take with this research?

I’ve submitted a grant, which looks like it will be funded by the National Institutes of Health, to use the interactive voice response technology as a treatment tool. Our original thought was to use the IVR as a way of looking at the natural history of drinking. How does drinking evolve over time? Can you pinpoint people who are about to evolve from drinking a little heavier than they should to a lot heavier? From problem drinking to alcoholism? If you can, then can you use that information to intervene.

How do you make the distinction between problem drinking or heavy drinking and alcoholism?

Basically, it revolves more around the behavioral consequences of drinking than it does the drinking per se — so getting into social trouble with your drinking, getting into police trouble with your drinking, being unable to control your drinking, having withdrawal symptoms when you don’t drink.

Do you think that the general public has a reasonable understanding of alcoholism? Are there some common misconceptions out there?

Yes, I’d guess that there are some misconceptions. One belief, which is certainly a misconception among college kids, is that you’re OK if you drink beer but you’d better stay away from the hard stuff. There is a belief with some that the consequences of drinking beer are somehow different from the consequences of drinking hard liquor. Of course, they are both forms of alcohol and you can as easily become alcoholic by drinking too much beer as you can by drinking too much hard liquor.

I think there’s probably also a misconception that so long as you don’t binge drink, it’s OK to drink a fair amount. There is the thought that you can drink four or five drinks a day on a regular basis and that’s not a problem. In fact, that is a fairly serious problem. Not necessarily because it’s going to lead to alcoholism, but because there are relatively serious health consequences.

How do you approach working to help someone who is an alcoholic as opposed to someone who’s a problem drinker?

In the case of an alcoholic, a lot of what Alcoholics Anonymous says is correct — that is, if you really have the disease alcoholism there’s a pretty high likelihood that in order to do OK you’re just going to have to stay away from alcohol. The loss of control aspect of drinking among alcoholics is so strong — meaning that when you take that first drink you’re very much more likely to keep drinking – that we really push total abstinence.

The treatment of people who are drinking too much but who are not alcoholic is different in a number of respects and it’s that group that my research will focus upon. In these cases, you’re less often looking at a situation where it’s just going to be impossible for the person to drink and keep it under control.

In fact, more and more of this treatment is taking place in primary care doctor’s offices. There’s a treatment that has developed over the last few years called “Brief Intervention” in which the doctor spends just a few minutes with the patient maybe on one occasion, maybe on three or four occasions, going over their drinking, discussing the health consequences, and advising them to cut back. There seems to be something about the physician-patient relationship that helps to drive that home with people and there is good evidence that it has a definite measurable impact.

Does the patient comes in wanting to discuss the problem more typically, or is it something a primary care physician picks up on during a physical?

Both. At Given, for instance, patients fill out a health questionnaire when they come for a physical. Among many others, it includes seven or eight questions concerning drinking. Key questions include how much they are drinking each day, whether they feel guilty about drinking, whether they drink in the morning, whether people’s comments about their drinking are starting to annoy them, those kinds of things. The docs review that information before they see the patient and it helps them to identify red flags.

If there appears to be a problem emerging, the doctor talks with the patient and gives them some information explaining the kinds of problems you can get into healthwise if you continue drinking at a high level.

That’s pretty standard policy throughout the country. My research won’t change that approach, but what we will do is enroll some of those patients for an IVR system so that when they sit down with the doctor and the doctor goes over their drinking rhythm, they can come to an agreement on a more reasonable level of drinking.

We’ll pick up on that information and invite people to call in everyday to the IVR system, completely anonymously, and report how much they drank in the last twenty-four hours. So we will have a control group that only gets the brief intervention from the doctor, then we will have a group that gets the brief intervention plus calling in every day to the IVR.

Do you think that the simple act of having to call each day and report on their drinking — putting it into words — may have the effect of making people slow down?

Yes, that’s another part of the research — there are two more study groups. The third group will have the brief intervention, the daily calls to the IVR, and we’ll also give monthly feedback to the doctor in the form of a graph showing what the agreed level of daily drinking was compared to the reported level of daily drinking. The doctor will forward that to the patient by mail with a letter reporting and encouraging progress. The fourth group will have all of the same procedures, but will add a payment to the patient for making the daily calls so we can see if it’s necessary to have that reward in order to get people to do this every day.

Could it be used as a way to track how these patients are doing, a way to see if someone is backsliding on their commitment?

Yes, it’s a totally new research but that’s exactly the kind of thing that we’re interested in. Even when it’s totally anonymous and the information goes nowhere, this procedure is useful just in terms of making people more aware of of how much they’re drinking? Treatment with this technology poses many questions now; as we continue to explore it further, it offers great potential for the future.