Introduction to the Special Issue: Implementing the Grand Challenge of Reducing and Preventing Alcohol Misuse and Its Consequences

The Grand Challenges for Social Work initiative, launched by the American Academy of Social Work and Social Welfare (AASWSW) in 2012, identified a series of 12 broad social work challenges. Each challenge addressed a “deeply significant problem widely recognized by the public whose solution is within our grasp in the next decade, given concentrated scientific and practical attention” (AASWSW, 2016). This special double issue of the Journal of Social Work Practice in the Addictions addresses the Social Work Grand Challenge called Reducing and Preventing Alcohol Misuse and Its Consequences (Begun, Clapp, & The Alcohol Misuse Grand Challenge Collective, 2016).¹ The AASWSW Grand Challenges initiative leadership situated the alcohol misuse challenge under the umbrella of “Close the Health Gap.” Solutions under this health-related umbrella are expected to “lead to broad gains in the health of our entire society” and promote greater health equity across the population.² Reducing and preventing the consequences of alcohol misuse would make major contributions by addressing one of America’s major health gaps.

Since the AASWSW posted the alcohol misuse grand challenge paper on alcohol misuse, members of the Alcohol Misuse Grand Challenge Collective have initiated several efforts to respond to this challenge. These have included disseminating the challenge itself to an interdisciplinary audience, organizing conference sessions that bring together scholars in the area, and producing this special issue of the Journal of Social Work Practice in the Addictions for scholars, practitioners, and other audiences. These efforts are intended to showcase what social work is doing to address the alcohol misuse grand challenge and to provide direction for the future.

WHY IT MATTERS

The Reducing and Preventing Alcohol Misuse and Its Consequences Grand Challenge effort is particularly meaningful because alcohol misuse is a large, significant, and compelling national and global problem related to many health and social concerns. Authors of the challenge paper elected to define alcohol misuse as involving “drinking in greater quantities or more frequently than is advisable, and may involve drinking in risky situations or circumstances” (Begun et al., 2016, p. 73). The U.S. Surgeon General defined it as use of the substance in such a manner that it causes harm to users or those around them (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016). In terms of health consequences, the World Health Organization (WHO) identified alcohol use as responsible for almost 6% of deaths globally (3.3 million annually) and just over 5% of the global disease burden (WHO, 2014). During 2011, the United Nations General Assembly adopted a resolution concerning the prevention and control of four leading noncommunicable diseases—all of which are exacerbated by alcohol misuse (United Nations, 2011). The WHO has published a goal of effecting a 10% decrease in harmful use of alcohol between 2015 and 2020 (WHO, 2015). In the United States, an average of just under 88,000 deaths annually are associated with alcohol misuse, making it the fourth leading cause of preventable deaths (Stahre, Roeber, Kanny, Brewer, & Zhang, 2014).

Alcohol misuse is a contributing factor in risk for injury, addiction, and dangerous drug interactions. Furthermore, it causes or contributes to health problems, such as lifelong, irreversible developmental complications from fetal exposure; significant damage to multiple organ systems in the body (e.g., brain, heart, liver, immune system); and the development of major disease conditions (e.g., some forms of cancer, Type II diabetes, liver and heart disease, as well as multiple types of psychiatric and mental health disorders). In addition to these physical health concerns, alcohol misuse is a frequent concomitant or prelude to many serious social, behavioral, economic, and legal problems affecting individuals, families, communities, and social institutions. These include family and other forms of interpersonal violence (e.g., intimate partner violence, child maltreatment, and sexual assault), driving under the influence (including mass transit drivers), suicidality, problem gambling, human trafficking, housing insecurity, legal and criminal justice system involvement, job loss or poor work performance, sexual risk taking, unintended pregnancy, and more.

Social workers play vital roles in addressing all these problems in the many settings in which they work. With concerted effort, social workers, along with allied professionals and the public’s support, can make significant progress toward reducing and preventing alcohol misuse and its consequences. The recent release of the U.S. Surgeon General’s (U.S. Department of Health and Human Services, Office of the Surgeon General, 2016) first report on alcohol, drugs, and health is further reminder of the need to redouble efforts to reduce alcohol misuse. The report was produced in recognition of the health and social problems associated with substance misuse, including alcohol, and the need for a comprehensive approach to address the problems in the United States (pp. 1–3).

THIS SPECIAL ISSUE

Our initial call for manuscripts was broad. We wanted to elicit a response from a variety of social work scholars engaged in work related to the aims described in the Grand Challenge paper. The result is presented here as 10 articles submitted by individuals and teams of scholars. The articles fall into two groups. One group addresses a more general set of issues, including articles that focus on specific populations that are critical to meeting the grand challenge. Indicative of social work, we were pleased to see that these articles address micro, mezzo, and macro level issues and solutions. The second group addresses a social work workforce development agenda, in particular, implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT). In addition, we conducted interviews on two topics not specifically addressed in the 10 articles that we also thought warranted inclusion—fetal alcohol spectrum disorders and the federal government’s role in meeting the grand challenge.

The General Papers

The general papers address several topics. With national attention focused on reducing health disparities (U.S. Department of Health and Human Services, n.d.), it is not surprising that two of the articles focus on this topic. One of these articles (Manuel) addresses whether treatment utilization for alcohol misuse and alcohol use disorders has increased, especially among Black, Hispanic, and Asian men and women, since passage of the Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) and “Obamacare.” Under the ACA, 20 million more Americans now have health insurance (U.S. Department of Health and Human Services, 2016). The ACA added new requirements for health insurance plans to include treatment for alcohol and drug problems. However, rather than increased utilization of services for alcohol use misuse and use disorders for all groups as hoped, Manuel found that treatment utilization increased for some racial and gender groups and decreased for others. The results must be viewed cautiously, because factors other than the ACA (e.g., patient preferences, stigma, provider biases, cultural attitudes, or other factors) might continue to inhibit more optimal levels of treatment use. We join the authors in calling for approaches such as culturally relevant services and greater use of models such as integrated behavioral health care as means of remedying inequities in treatment for alcohol misuse and use disorders. With uncertainly in the national health care environment given the new administration’s desire to take a different course than that mandated by the ACA, those involved in preventing and treating substance misuse and substance use disorders will be carefully monitoring the health insurance environment and advocating to ensure a continued focus on increasing access to treatment.

The second article on racial disparities examines whether government-funded substance use treatment programs in counties with majority and minority Black populations differed in their provision of evidence-supported treatments (ESTs) from 2008 to 2010 (van den Berk-Clark, Patterson Silver Wolf [Adelv Unegv Waya], and Williams). After controlling for a variety of agency or organization and community factors, findings suggest that although programs in majority Black communities might provide somewhat fewer ESTs than those in minority Black communities, programs in both community types embrace EST use. Although the authors recommend viewing the findings cautiously due to limitations in the variables available for inclusion and the self-report data of treatment personnel, the findings tend to contradict other studies and popular beliefs that Blacks receive inferior treatment. With the scientific community focused on the need to promote the use of ESTs and interventions, more research like this is needed to determine whether, how, and where ESTs are being used.

Two articles turn our attention to programs addressing alcohol misuse among adolescents and emerging adults. One describes programmatic features relevant to the growing Recovery School movement (Holleran Steiker and McElrath). This article is a useful introduction and primer for those interested in high school settings specifically designed for young people who are in recovery from alcohol and drug problems. The article emphasizes the need for such programs because many students in typical high school environments face significant pressure to use alcohol (as well as other drugs). Students in recovery high schools generally have access to a variety of supportive services that help them sustain recovery while earning their high school degree, a necessary credential for engaging in the workforce and moving toward a productive life as an adult. Another article related to youth in this special issue explores the organizational characteristics that empower staff and volunteers in community coalitions that target underage drinking (Powell, Gold, Peterson, Borys, and Hallcom). It is not surprising that empowerment coalitions like these received attention in the U.S. Surgeon General’s recent report. Mobilizing community members is key to solving problems such as underage drinking, and keeping staff and volunteers engaged is a necessary condition for effective coalitions. The study found that although there was some overlap, different factors affected staff and volunteers’ sense of empowerment and views of coalition effectiveness. For example, among staff members, the opportunity to engage in specific roles was particularly important, while fostering leadership and a sense of community was critical for volunteers. With knowledge such as this, more emphasis can be placed on training and developing staff and volunteers to increase coalition involvement and effectiveness.

The Hohman, Barker, and Woodruff team studied the intersection between trauma and posttraumatic stress disorder (PTSD), which are often related to alcohol misuse. Their focus was clients in programs designed for individuals arrested for driving under the influence (DUI). The likelihood of experiencing particular traumatic events differed for men and women in this treatment population, but clients with higher blood alcohol concentrations were more likely to screen positive for PTSD. As a means of preventing future DUI incidents and improving client overall well-being, the authors implore those working in DUI programs to identify trauma, help clients see the relationship between trauma and alcohol use, and refer clients to services that can help address trauma when needed.

The last of our general topic articles discusses the Grand Challenge implications of three technology-based interventions for reducing alcohol misuse and its consequences (Resko, Brown, Lister, Ondersma, Cunningham, and Walton). With the growing emphasis on teletherapy and applications accessed via smartphones and other electronic devices to provide physical and mental health services, it is no wonder that interest in using technology to deliver interventions to reduce substance misuse is growing. These interventions are particularly attractive for their ease of access, availability, privacy considerations (and challenges), and cost effectiveness. They seem destined to grow in popularity among people of all age groups. In the quest to reduce alcohol misuse and its consequences, we must experiment with a variety of tools to expand our reach and attract more individuals to use them. We also need to remain mindful of their limitations.

The Workforce Development Papers

Responding to the alcohol misuse grand challenge requires a workforce dedicated to reducing and preventing alcohol misuse and its consequences. Four of our special issue articles focus on workforce development. To reduce alcohol misuse and its consequences, the Substance Abuse and Mental Health Services Administration (SAMHSA) has provided substantial funding to see that health and allied health professionals are prepared to engage in the evidence-based practice called SBIRT. These four articles describe initiatives to prepare social work professionals to provide SBIRT. Although there will continue to be a need for specialized alcohol treatment services, the alcohol misuse grand challenge cannot be met without interventions that tap into the problems much earlier in their development and present motivating opportunities and access to a wider audience. Thus, these training projects are responsive to calls for bringing alcohol misuse interventions into general practice arenas and mainstream social work practice across setting types.

In the first of these articles, the team of Carlson, Agley, Gassman, McNelis, Schwindt, Vannerson, Crabb, and Khaja found that following SBIRT training, master’s of social work (MSW) students at a large, urban, public university made gains in perceived competence, comfort making alcohol-related statements, and positive attitudes toward working with patients who drink at risky levels. The training included Microsoft PowerPoint presentations, online educational modules, and face-to-face training that included simulated role-playing. A second of these articles (Sacco, Ting, Crouch, Emery, Moreland, Bright, Frey, and DiClemente) reports on an SBIRT course that included didactic sessions, role-playing, and videotaped standardized patient interactions for MSW students. Sacco and colleagues also report that SBIRT behaviors, confidence, skills, and knowledge increased following the course. In a third article, Putney, O’Brien, Collin, and Levine prepared MSW as well as a smaller number of bachelor’s of social work students and a group of field instructors to use SBIRT. The students’ training was based on existing SBIRT curricula adapted for social workers and was embedded in the social work foundation curriculum. Training was online and in class and included skills practice. Field instructors were trained in a 3-hr seminar that also included information on mentoring students in SBIRT use. Similar to the other studies, Putney and colleagues found evidence of SBIRT training’s feasibility and acceptability and preliminary evidence of its effectiveness.

In addition to SBIRT training, and as noted in discussing the Hohman et al. article earlier, trauma-informed care has gained social workers’ attention (SAMHSA, 2015). The fourth workforce development article (Topitzes, Berger, Otto-Salaj, Mersky, Weeks, and Ford) reports on efforts to combine trauma services with SBIRT (they call it T-SBIRT) with a sample comprised largely of low-income African American and Latino clients served by community health clinics. The investigators found T-SBIRT to be feasible and acceptable with the potential to increase treatment referrals for substance misuse or substance use disorder and trauma. They also point to the need for integrating behavioral services in primary health care services. Those of us dedicated to preparing the next generations of social workers hope that SBIRT for alcohol misuse and related problems will become part of the education of all students in social work, as well as other physical and behavioral health disciplines.

The Interviews

Finally, we invited two scholars to participate in interviews about topics we thought were important to include, but were not covered in the manuscripts we received. In the first interview, Dr. Peggy Murray, a senior official with the National Institute on Alcohol Abuse and Alcoholism (NIAAA), spoke with us about NIAAA’s research mission, research agenda, and the global challenge of reducing and preventing alcohol misuse and its consequences. Murray emphasizes opportunities for social workers to obtain research funding and to use data sets from other studies. She describes major NIAAA-funded studies on the adolescent brain and cognitive development, the genetics of alcoholism, medication-assisted treatment, fetal alcohol spectrum disorders (FASD), and college drinking. Murray underscores the importance of screening and brief intervention and efforts of the World Health Organization, the Organization for Economic Cooperation and Development, and the United Nations to reduce and prevent alcohol misuse and use disorders and their consequences. She encourages social workers to become part of research teams tackling the big issues in alcohol misuse because the social work perspective is always needed. For the second interview, we asked Dr. Shauna Acquavita, whose work has been in physical and behavioral health, including addressing substance use disorders among pregnant women, to talk with us about fetal alcohol exposure. Preventing fetal alcohol exposure is critical in meeting the grand challenge of reducing and preventing alcohol misuse and its consequences. Acquavita defines FASD, updates us on efforts to prevent it, and discusses social work’s roles in the process, especially collaboration with members of other disciplines in concerted efforts to prevent drinking during pregnancy and to help those with the range of FASD achieve their full potential.

MOVING FORWARD WITH THE CHALLENGE

Social work is not alone in recognizing the significance of alcohol misuse as a major contributor to physical health, mental health, and social problems. Members of the Alcohol Misuse Grand Challenge Collective believe that demonstrable progress can be made toward reducing alcohol misuse and preventing its consequences in the next decade. Doing so requires new approaches to collaboration—multidisciplinary, interdisciplinary, and transdisciplinary—as well as multisectorial approaches that transcend traditional lines between systems and levels of study or intervention. Social workers often use the term biopsychosocial to refer to this comprehensive approach. Sustainable solutions will require significant, transformative, and innovative strategies (Begun et al., 2016).

In conclusion, this special issue of the Journal of Social Work Practice in the Addictions presents important contributions for responding to the Social Work Grand Challenge of Reducing and Preventing Alcohol Misuse and Its Consequences. We hope that the journal readership, practitioners, scholars, policymakers, educators, and the public are inspired to join us in addressing the alcohol misuse grand challenge because much remains to be done. By joining together, we can develop and invest in additional initiatives for responding to the challenge. Each of us can also find innovative ways to become engaged in the effort and assume leadership roles in organizing responses to the challenge. With concerted efforts, the cumulative effect can be significant reductions in alcohol misuse and its consequences.

Notes

¹ The original Alcohol Misuse Grand Challenge paper can be found at http://aaswsw.org/wp-content/uploads/2015/12/WP14-with-cover.pdf. It has been reprinted with minor changes as Begun, Clapp, and The Alcohol Misuse Grand Challenge Collective (2016).

² More information on Close the Health Gap Grand Challenge can be found at http://aaswsw.org/grand-challenges-initiative/12-challenges/close-the-health-gap/.