The drive to drink
Dr. John Helzer is a professor in the Department of Psychiatry in UVMs 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 Im doing now explores a new methodology that has never
been applied as a treatment device. In fact, its hardly been
used in medicine at all. The pioneering work in using this technology
was led by colleagues Ive 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 youll 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 its also a technology that can lend itself very nicely to
other uses. At the Vermont Alcohol Research Center its used as
a device for having people report their alcohol consumption on
a daily basis, information thats been quite difficult to gather
in the past.
This is very useful information for a number of reasons, but its
just not very accurate when it isnt 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 peoples responses different given that theyre talking to a computer rather than a person?
Absolutely. There is good evidence that theyre 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?
Were 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. Well also
be able to look at factors like mood states that may be responsible
for drinking on a daily basis. Theres 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.
Whats the next step you hope to take with this research?
Ive 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 dont drink.
Do you think that the general public has a reasonable understanding of alcoholism? Are there some common misconceptions out there?
Yes, Id guess that there are some misconceptions. One belief,
which is certainly a misconception among college kids, is that
youre OK if you drink beer but youd 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 theres probably also a misconception that so long as
you dont binge drink, its 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 thats not a problem. In fact, that is a fairly
serious problem. Not necessarily because its 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 whos 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
theres a pretty high likelihood that in order to do OK youre
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 youre 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 its that
group that my research will focus upon. In these cases, youre
less often looking at a situation where its 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 doctors offices. Theres 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 peoples
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.
Thats pretty standard policy throughout the country. My research
wont 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.
Well 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, thats 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 well 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 its 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, its a totally new research but thats exactly the kind of thing that were interested in. Even when its totally anonymous and the information goes nowhere, this procedure is useful just in terms of making people more aware of of how much theyre drinking? Treatment with this technology poses many questions now; as we continue to explore it further, it offers great potential for the future.