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A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009

• Charli Eriksson 1 ,
• Susanna Geidne 1 ,
• Madelene Larsson 1 &
• Camilla Pettersson 1  

Substance Abuse Treatment, Prevention, and Policy volume  6 , Article number:  8 ( 2011 ) Cite this article

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Alcohol and drug prevention is high on the public health agenda in many countries. An increasing trend is the call for evidence-based practice. In Sweden in 2002 an innovative project portfolio including an integrated research and competence-building strategy for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This research strategy case study is based on this initiative.

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The data in the case study has been compiled using multiple methods - administrative data; interviews and questionnaires to project leaders; focus group discussions and seminars; direct and participatory observations, interviews, and documentation of implementation; consultations with the NBHW and the NGOs; and a literature review. Annual reports have been submitted each year and three bi-national conferences Reflections on preventions have been held.

A broad range of organisations have been included in the NBHW project portfolio. A minority of the project were run by Alcohol or drug organisations, while a majority has children or adolescents as target groups. In order to develop a trustful partnership between practitioners, national agencies and researchers a series of measures were developed and implemented: meeting with project leaders, project dialogues and consultations, competence strengthening, support to documentation, in-depth studies and national conferences. A common element was that the projects were program-driven and not research-driven interventions. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. The research strategy also includes elements of participatory research.

Conclusions

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organisations. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

Introduction

Alcohol and drug prevention is high on the public health agenda in most countries. The national initiatives differ, although action plans have been proposed by international organizations such as WHO [ 1 ]. Moreover, there is an increasing demand for evidence-based alcohol and drug prevention, causing an increased emphasis on research for prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. This means that prevention research needs to move "from basic to more and more applied research; from descriptive hypothesis-generating pilot studies to full-fledged, methodologically sophisticated, hypothesis-testing studies; from smaller to larger samples for testing; from greater to lesser control of experimental conditions; from more artificial 'laboratory' environments to real-world geographically defined communities; from testing the effects of single intervention strategies into more complex studies of multiple strategies integrated into intervention systems; and from research-driven outcome studies to 'demonstration' projects that evaluate the capacity of various types of communities to implement prevention programs based on prior evaluations" [[ 9 ], p 183]. It has also been more than 10 years since Nutbeam [ 10 , 11 ] noted the gap between the need for knowledge and the priorities among researchers.

Many years have passed since these recommendations, but still the gap between evidence and practice has not been bridged despite important achievements in implementation research [ 12 ], designs for effectiveness and translation research [ 13 ], and a series of initiatives regarding the evidence-practice gaps [ 14 – 22 ]. The call for more practice-based evidence is a challenge for policy-makers, practitioners, researchers, and funding agencies [ 17 , 23 ]. In several countries research on alcohol and drug issues has been incorporated into addiction research centres [ 24 – 28 ]. For many years much addiction research has been the product of specialized research centres rather than the contribution of standalone scientists. Moreover it is the specialist centres, in collaboration with the national funding agencies, which today assert leadership, set agendas, and help determine standards [ 24 ]. However, a common element in the missions of these centres is monitoring the substance use in the population, its causes, and courses, while prevention research is not high on the agendas. Furthermore, the establishment of national centres demonstrates the political administration's emphasis on scientific, evidence-based policies, but at the same time demonstrates the view that credible research is best performed within independent scientific bodies [ 26 ].

In Sweden in 2002 an innovative project portfolio for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This included an integrated research and competence-building strategy to strengthen alcohol and drug prevention. This case study aims to describe and analyse this initiative.

AD prevention in Sweden - legislation, national action plans, resources, and actors

Sweden has a long tradition of a restrictive alcohol policy [ 29 ]. The temperance movement became a powerful actor in the Swedish alcoholic beverage policy [ 30 ]. Moreover, Sweden is one of the few countries in Europe with a narcotics policy that aims to create a society entirely free of illicit drugs [ 31 ].

The overall goal of the Swedish action plan on alcohol and narcotics is to promote public health by reducing the medical and social harm caused by alcohol and to create a drug-free society. The strategy for achieving this goal with regard to alcohol is to reduce the total consumption and prevent harmful drinking, taking into account differences in living conditions among boys, girls, men, and women. Six priority sub-goals have been adopted: alcohol should not be consumed in transport contexts, at workplaces, or during pregnancy; children should grow up in an alcohol-free environment; the age of alcohol debut should be postponed; drinking to point of intoxication should be reduced; there should be more alcohol-free environments; and illicit alcohol should be eliminated. The sub-goals in the action plan on narcotics are to reduce recruitment to drug abuse, induce people with substance abuse problems to give up their abuse, and to reduce the supply of drugs. Interventions targeting children, adolescents, and parents are of high priority [ 32 ].

Swedish alcohol policy is based on a combination of taxed-based price controls and the alcohol retail monopoly in order to limit the availability and accessibility of alcohol [ 32 ]. There is strong evidence for the preventive effects of an alcohol retail monopoly [ 33 , 34 ] and high prices on alcohol are regarded as one of the most effective ways of reducing total alcohol consumption and alcohol-related problems [ 35 ]. When Sweden entered the EU in 1995, the conditions changed and Sweden could no longer have an independent alcohol policy. For example, the availability of alcohol increased as a result of changed rules for private import, and alcohol taxes had to be adjusted. The numbers of alcohol shops as well as their opening hours have also increased remarkably since 1995 [ 29 ]. The increased movements across borders have also had an influence on the illicit drugs market. Almost all narcotics that are consumed in Sweden have been produced outside the country. A well-developed international collaboration is therefore of high importance for the limitation of illicit drugs in Sweden [ 32 ].

An effective alcohol and drug policy also requires national coordination. The Swedish government has established a national council for alcohol, narcotics, doping, and tobacco. The council consists of members of public authorities, civil society, and researchers, and is led by the State Secretary of the Ministry of Health and Social Affairs. The council is commissioned to advise the government on issues about alcohol, drugs, doping, and tobacco and to present information about research results [ 36 ].

There is a need for the different sectors in society to increase and deepen their cooperation for an effective prevention of the use of alcohol, tobacco, and drugs. In the Swedish action plan on alcohol and illicit drugs as well as in the government bill for public health the importance of the voluntary sector is emphasized [ 36 , 37 ]. In the latter document, A renewed public health policy , it is stated that cooperation between the state and the voluntary sector should be expanded and that the conditions for the voluntary sector's work should improve [ 37 ]. An agreement about the relations between the government, the voluntary sector in the social setting, and the Swedish Association of Local Authorities and Regions has recently been developed through a dialogue between the parties. The dialogue is another way for the government to call attention to the voluntary sector and to its ambition to strengthen the sector and improve its conditions. The goal of the agreement was to strengthen the independence of the voluntary sector as moulders of public opinion and to support the development of public medical service carried out by the voluntary sector [ 38 ]. The Swedish voluntary sector has a long tradition of alcohol prevention, especially the temperance movements [ 39 ].

NGOs in Sweden

The Swedish voluntary sector is both different and similar to those in other countries. A major difference lies in its history in that, for instance, as early as in the 16th century the responsibility for health and care was organized under the state instead of in the regime of the church. In parts of Europe the church still is an active actor in health and care [ 40 , 41 ]. Also, popular mass movements have played an important role in the development of Swedish society [ 41 , 42 ]. The Swedish voluntary sector is as large as in other industrialized countries, although quite different in character. It is dominated by organizations in the cultural and recreational field, mainly sports organizations. Since the early 1990s the Swedish voluntary sector has expanded, particularly in the two areas of culture and recreation, as well as in the area of social care [ 43 ]. It can also be called membership-based; almost everyone in Sweden is a member of some organization. Because of these differences in history and structure in different societies, the voluntary sector plays different roles. In Sweden, NGOs are more of a complement then a substitute for state programs, and have an important role as forerunners and innovators [ 44 ].

Previous research has shown that the Swedish voluntary sector was highly dependent on public financing, which is partly correct. Looking at the entire sector together, about 30 percent of its financing comes from government funding. However, within the health care and social service sector, public financing stands for more than 70 percent. That is quite high in comparison with other European countries, but not the highest [ 45 ].

Support to NGOs today

Organizational grants.

The National Board of Health and Welfare (NBHW) has a government commission to administer the grants to national organizations for the disabled, the elderly, and relatives of elderly persons; to national organizations in the social setting; and to national and local organizations. For the moment this amounts to about 300 million SEK to about 100 organizations. Also the Swedish National Institute of Public Health has funds to distribute to NGOs or to other organizations working together with NGOs. The Swedish State Inheritance Fund is also a possible source of funding for NGOs. They administer over 300 million SEK a year to provide grants to NGOs working with children, youth, and the disabled. In addition other governmental agencies such as the Swedish National Board for Youth Affairs also support NGOs.

Project grants

In the late 1990s a new system of awarding grants to NGOs in the arenas of alcohol and narcotics, vulnerable children and their families, and violence against women was prepared. The previous systems were from the late 1970s and early 1980s, and during the 1990s many investigations recommended a better, more structured follow-up and evaluation of the NGOs' work. One new idea that emerged during the 1990s was increased performance management, that is, the need to point out achieved results and effects of different activities. It was emphasized that the government should not interfere with the running of the organizations but does have the duty to monitor the use of the grants. There was also a desire that renewal efforts and collaborations should be encouraged and supported.

In the late 20th century grants were awarded through the Swedish National Institute of Public Health (with money from the Swedish State Inheritance Fund) to a number of alcohol and drug prevention projects. A final report and an internal evaluation were required from the applicants. There was also an external evaluator, who conducted an evaluation of 11 projects focusing on their working processes [ 46 ]. Among the lessons learned from this evaluation were that the way of working should be characterized by frequent contacts and dialogue between the funding agency and the project, and also by supervision. The evaluation report also suggested that the support to the project leaders should be reviewed with regard to the possibility of different types of need-based support. Moreover, the short-term thinking in the funding of these kinds of projects was not in line with the needed time-frame.

Setting the Scene: NGO strategy for alcohol and drug prevention

Non-governmental organizations have received grants from the NBHW to conduct alcohol and drug preventive work in a special venture since 2003 [ 47 ]. This initiative is part of the national plan of action to prevent alcohol-related harm and the national plan of action against narcotics and comes from the Ministry of Health and Social Affairs. The working committee, which decides who will get funding, consists of members of the NBHW, the Swedish National Institute of Public Health, and the Swedish National Board for Youth Affairs (previously members of the Swedish Alcohol Committee and the Swedish National Drug Policy Coordinator were included). The working committee, after consulting the research team at Örebro University, also decides which projects will be studied in-depth. NBHW's initiative represented a new way of thinking. One point of departure was to create a project portfolio with a broad combination of organizations to mobilize many forces in the alcohol and drug preventive work. The initiative also contains supervision for the project leaders, competence support through regular meetings for project leaders, and an integrated Research & Development (R&D) investment (Figure 1 ).

Integrated research and development for NGO alcohol and drug prevention .

Need for knowledge building and learning

There is an increasing trend towards promoting evidence-based public health initiatives. International expert committees have presented the state of science with regard to alcohol prevention: Alcohol Control Policies in Public Health Perspectives [ 48 ]; Alcohol Policy and the Public Good [ 49 ]; and Alcohol: No Ordinary Commodity -Research and Public Policy [ 33 , 50 ]. National authorities have presented reviews presenting evidence for practitioners and politicians [ 51 – 53 ]. However, there are important knowledge gaps to be filled. Among these is the lack of effectiveness studies where the external validity is high. If we want to see more evidence-based practice we need more practice-based evidence [ 54 ]. This means an improved emphasis on cooperation between researchers and practitioners [ 10 ].

A comprehensive perspective on the concept of knowledge, including scientific and practical knowledge as well as practical wisdom, is needed. Scientific knowledge about alcohol and drug issues needs to be complemented with knowledge about methods for alcohol and drug prevention. As in other public health fields, ethical issues and practical wisdom are important [ 55 ]. Moreover, the science, craft, and art of implementation are of utmost importance. There are many reasons besides practicalities that are significant for the implementation of programs [ 7 , 56 ]. In a recent review, 23 different factors were found that were of importance for the degree of the implementation [ 12 ] and that also have a great impact on the program effects.

Research on alcohol and drugs has often been organized in special research institutes, which often focus on basic research on alcohol and drugs [ 24 – 28 ]. This basic research is related both to basic biomedicine as well as social and behavioural studies. Another activity, which has been accorded great prominence, is the monitoring of alcohol and drug use in the population in general as well in different groups. Intervention research has been given less prominence in these often national research institutes. However, the national agencies, such as the Swedish Institute of Public Health, have been involved in the evaluation of different intervention projects. So far research on NGO-driven alcohol and drug prevention has been almost completely lacking. Research has been a more or less exclusive activity for the university. However, this has been based on the trust in the impartiality and objectivity of the university-based researchers. The downside of this position is that this type of research may lack the necessary cultural awareness and insights necessary for a proper understanding of basic factors for successfully planning intervention programs as well as evaluating research efforts. In other words the roles of the researcher in intervention studies need to be addressed. In a recent study, Holmila et al. [ 57 ] outlined three different positions for researchers in community intervention studies. The researcher can be an external observer, not taking part in the preventive activities - acting as an unobtrusive observer . The researcher assumes no responsibility for the design or implementation of the projects but acts as an independent conductor of process evaluation and observer of project outcomes. Another position is to be a researcher-as-technical advisor . In this role the researcher has responsibility for evaluation but also takes the responsibility for providing scientific advice on effective preventive strategies if asked for [ 58 – 60 ]. This could include training and technical assistance to the projects. Progress reports on findings as well as results from different on-going studies can be presented to the practitioners, which may use this information as they desire. A third type is researcher-as-designer , where the project is designed by the research team in partnership with the practitioner. The researcher is an active participant in project planning as well as the process of carrying it out and evaluating the effects. This approach is particularly useful when the goal is to test one or more designed prevention strategies under as close to optimal conditions as possible. Examples of such in Sweden are the STAD Project in Stockholm [ 61 ] and the Trelleborg Project [ 62 ]. The Örebro Prevention Program is an example of a program where all parts of the process were in the hands of the researchers [ 63 ].

The present paper aims to describe and analyse alcohol and drug prevention supported by the NBHW and implemented by NGOs in Sweden during 2003-2009 with a special emphasis on research and development for an evidence-based practice. The case study analyses also the integrated research strategy and its main components.

Three research questions will be addressed:

Which types of organizations and projects have received grants from the NBHW for AD prevention?

What types of research and development activities for an evidence-based practice have been included?

How can a trustful partnership develop between practitioners, national agencies, and researchers?

Methods and materials, case study approach.

A case study method was chosen as the intention was to understand a real-life phenomenon in depth and the contextual factors were highly pertinent to the study [ 64 ]. This method investigates according to Yin contemporary phenomenon in depth and within its real-life context, especially when the boundary between the phenomenon and context are not clearly evident. Moreover, the case study approach copes with the situation such as in this case in which there will be more variables of interest than data, which leads to the need for multiple sources of evidence, with data needing to converge in a triangulating fashion. Furthermore, benefits from the prior development of theoretical propositions to guide data collection and analysis [ 64 ]. The present research strategy case study is on an organisational level. It studies a social process in a situation in which we have little knowledge of the phenomenon, integration of research in alcohol and drug prevention run by NGOs. Case studies as a main research strategy are selected as this is a unique case in Sweden, the impossibility to isolate the process and the intention is to combine research and action [ 65 ].

An embedded single-case design was chosen for the study. All the projects run by the NGOs are seen as embedded units of analysis in the study with special emphasis on the fourteen in-depth studies.

Participants

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The participants in this research strategy case study are the NGOs applying for funding to the NBHW and especially those NGOs that have received funding during 2003-2009. The project leaders and managers in the NGOs as well as the members of the different target groups are also participants in this study. Moreover, staff at the NBHW as well as other stakeholders is included.

Case study questions

When the research program started a set of overall research questions were developed. In this paper the focus is in one of these, how can a trustful partnership for practice-based research be developed? Additional questions concerns: the role as a project leader in NGOs, the impact of competence development, methods for documentation of project development, and the added value of running projects in NGOs.

Case study protocol

A plan for the research and development activities was developed the first year and amended each year after the completion of the annual report to the NBHW. This plan consisted of several parts relating to the overall activities as well as the different in-depth studies. Notes were taken at meetings and as part of the strategy a series of presentations as progress reports were given to, project leaders, NGOs and the NBHW.

Development of a Case Study Database

In the present study a broad range of methods was used in the data collection. This includes six types of data.

Administrative data

The applications from the NGOs to the NBHW as well as the funding decisions were the initial data, which was complemented by bi-annual as well as annual progress reports from all funded projects. These reports, which were submitted following a format developed by the research team, gave information on implementation and goal achievement as well as reflections on barriers and facilitating factors. The research team introduced this approach at a meeting with the project leaders, and this reporting resulted in an annual report to the NBHW on the progress of the alcohol and drug prevention projects run by the NGOs.

Interviews and questionnaires to project leaders

Data was collected from project leaders and their organizations in the years when funding was received from the NBHW. In 2003, 2005, 2007, and 2009 all project leaders were invited to respond to a questionnaire containing questions on being a project leader in a non-governmental organization. If the same project leaders were responsible for a project for more than one year they responded to more than one questionnaire. Most of those who answered the 2003 questionnaire also answered the 2005 questionnaire, due to the fact that many of those projects receiving funding in 2003 also were being funded in 2005. In total, 84 persons participated in the questionnaire study over the years. Of these, 38 project leaders answered the questions more than one year.

Focus group discussions and seminars

Thematic discussions were held as a part of the meetings with the project leaders. These highlighted special issues related to the practice of alcohol and drug prevention. Moreover, a series of joint seminars with NGOs and the research team have been held at national and organizational conferences focusing on different projects.

Direct observations, participatory observations, interviews, and documentation of implementation of the in-depth studies

The research team collected information by a variety of methods during the planning, implementation, and evaluation of the in-depth studies. Part of this data has been used in the analysis, resulting in separate reports and scientific publications. However, in this context more process-related data will be used to give insights into the development of the partnerships between researchers and practitioners.

Consultation with the NBHW and the NGOs

In the present paper information retrieved during the management of the NBHW support to the NGOs will be an additional source of information. Regular meetings have taken place with the steering committee and the senior administrative officer, who have been the same persons during all years. The consultations with the NGOs were more intense for those organizations selected for in-depth studies, but several meetings have also taken place with other organizations. Apart of the in-depth studies was feedback on preliminary results from different studies; this never radically changed the interpretation of results but did add valuable information.

Literature review

A systematic review of the research strategies for alcohol and drug prevention has been carried out as an integral part of the research program. A number of publications related to collaboration between researchers and practitioners were found. Special thematic sections and series have been looked for. Among the key words are addiction research centre, alcohol and drug research, preventive research, practice-based research, and evidence-practice gaps.

Analytical methods

The analytical approach in this case study follows a common strategy used in research programs: to start with the ordinary preventive activities and then study what is happening [ 66 , 67 ]. Using a naturalistic approach, which is always practice-based, it has been important to let different actors and stakeholders into the knowledge-building program. This also has implications for the selection of research and evaluation methods, given a need for mixed-method approaches [ 68 – 70 ]. In studies of effects, quantitative approaches are essential, but important contributions can be achieved if qualitative studies are also included [ 71 , 72 ]. The mixed-methods approaches have been developed for some of the more extensively studied programs, which also will be included in doctoral dissertations [ 73 , 74 ].

The analysis starts with a quantitative description of the investment in NGOs by agencies awarding grants and an analysis of which organizations and projects that were supported. The types of organizations are analysed with regard to their main focus or mission. Then the investment in research is described including an overview of the participants in different empirical studies using a range of data collection methods. This includes a description of how the embedded units, the project in the NBHW portfolio, have been documented and presented in annual reports using a format for the written reports based on questions and answers in the case study database [ 64 ]. The two types of in-depth studies are briefly presented: effect studies and studies of process and implementation.

An analysis of the experiences of cross-project comparisons as well as using the multiple sources of evidence in the case study database follows. The different measures in the research program was developed in order to foster a trustful partnership is then presented. These measures were assessed by all project leaders in the annuals reporting to the research team, which reviewed the content of the research strategy each year in the annual report to the NBHW. The implementation of the research strategy with regard to evaluation initiatives together with the NGOs as well as in-depth studies was carefully documented over the years and used as indicator for developing a research partnership with the NGOs. In this case study the focus is on the implementation of the research and evaluation efforts and not on the outcome of the alcohol and drug prevention program. This has been reported in other publications [ 47 ]. The different types of data and perspectives included in the case study database are used for triangulation and finding key elements and mechanisms in the research strategy. In this case study a mixed-methods approach means parallel mixed data analysis, i.e. parallel analysis of qualitative and quantitative data from different sources. Moreover, integrated mixed data analysis also occurs in the analysis of the project portfolio and subsequent development of research initiatives. To grasp the complexity and inclusiveness of integrated methods the term inference has been proposed as the last and most important stage of research [ 70 ]. The inference process consists of a dynamic journey from ideas to results in an effort to make sense of data. In our case study the regular project leader meetings as well as the preparation of the annual evaluation and reporting to the NBHW are key activities in this process of drawing inferences. Key concepts in an integrative framework are inference quality, which is related to design quality, interpretative rigour, and inference transferability.

The results will be presented according to the three research questions. The calls for applications resulted in many proposals from many different organizations for a variety of projects engaging many project leaders.

Investing in the NGOs - Allocation of Grants 2003-2009

Since 2003 10-15 million SEK per year have been administered to this special venture (Table 1 ). The government's decisions have over the years differed somewhat according to which target groups are being specially addressed in the calls for grant applications. For the first period, which was a two-year period, the call was broad. For the second period, 2005, the main part of the grants went to projects from the earlier period. From 2006 to 2009 the target groups have been children, youth, young adults, and the workplace according to the national action plans. It has also been emphasized that the projects would be new or in the process of expanding existing activities.

About one in four applications were awarded a grant. The amount of funds provided to NGOs varies. The minimum amount of funding for one year was 40,000 SEK and the largest amount was 1,200,000 SEK. Many organizations have been funded for several years. Over the years 2003-2009 the NBHW has in total apportioned about 80,000,000 SEK to the NGOs. In addition a yearly grant has been awarded to an integrated Research & Development (R&D) program as well as funds for administration and information activities. The total allocation from the NBHW has been 95,000,000 SEK, covering 135 projects in 69 organizations funded during these years.

The projects differed in size. Table 2 presents these 219 project grants over the years 2003-2009. The reason for this lower number of project (135) is that 50 projects have been funded over more than one year, 26 projects over two years, 17 projects over three years, and two projects over four and five years each. The first period, which covered two years, had the highest number of large projects. Moreover, the number of funded project has increased between 2005 and 2008 and the number of large projects has remained relatively stable since 2005.

Organizations and projects

The strategy to involve a broad range of organizations has been successful. In Figure 2 the 69 organizations and the 135 projects are presented according to type of organization. The largest number of projects were run by the nine alcohol and drug organizations. More than half of these projects were run by the Swedish temperance organisation IOGT-NTO (24 of 38 projects) amounting to 15 million SEK. The majority of these were small one-year projects, except for two programs where effect studies were conducted by the research team and the organization jointly. Between 15 and 20 projects were run by organizations focusing on social work, assistance, and ethnic groups. About 10 projects were run by sports, adult education, and religious organizations respectively. Furthermore, 14 projects were set up by two umbrella organizations each consisting of a number of member organizations.

Organizations and projects in different types of organizations according to main objectives .

The projects have different primary target groups for their activities. A majority of the projects have children or adolescents as target groups. Some of these projects are focused on young girls with the aim of promoting self confidence and a positive self image. Sports organizations have been developing alcohol and drug policies including anti-doping initiatives. Projects run by ethnic groups have as their target group members of their organizations including children, adolescents, and parents. A few projects have the workplace as the arena for intervention.

During the first years, three community-based projects were funded. These aimed to reduce drugs in two parts of Stockholm and the island Gotland. The strategy included a range of activities and collaboration with different actors. A broad membership in the organizations seems to be important for the sustainability of the community-based prevention.

Only one project has reduction of availability as its focus. This project focused on following up the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and the effect of different strategies to influence shops to comply with the law [ 74 ].

Internet has a great potential in promotion and preventive work [ 76 ]. The majority of the organizations have their own website on the Internet and about one third have a project-specific site. The organizations used information technology as a source of health information in three projects, as an intervention medium in four, for professional development in two, and as a research instrument in one project. The use of e-screening as a tool for drug prevention is studied by researchers at Karolinska Institute. There are still very few scientific evaluations of the use of Internet in drug prevention [ 77 ].

Basic characteristics of the project leaders in the alcohol and drug prevention projects are given in Table 3 . All four years the proportion of women was larger than men; about two of three project leaders were women. Most of the project leaders belonged to the age group 41-50 years in the early periods (2003/2005) while in the later periods (2007/2009) an increased proportion of the project leaders were 50 years or older. Moreover, nearly one in ten project leaders was 30 years or younger. Many of the project leaders in volunteer work were members of the organization before being appointed project leaders (Table 3 ). In 2003 eight of ten project leaders were members compared with four of ten in 2007 and 2009. Nearly half of the project leaders were also doing volunteer or non-paid work in the organization. No gender differences were found in the prevalence of non-paid work.

Investing in Research and Development

A research and evaluation strategy was developed by the research team at the School of Health and Medical Sciences, Örebro University. This strategy rests on collaboration with the NGOs through regular meetings with all project leaders, development of systematic documentation of project objectives, activities, and results, annual reports to the NBHW, and biannual national conferences Reflections on prevention (2006, 2008, and 2010). The role of the researchers can most closely be characterized as researchers as technical advisors . In some projects the researcher had the position of an unobtrusive observer -for instance in following up some projects in which no longitudinal data collection was included. In addition, in no project did the researcher have the position of researcher as designer . Moreover, separate competence development and discussion of evaluation studies were conducted with a smaller number of organizations. The steering committee at the NBHW also decided, after consulting the research team, on a number of in-depth studies. Fourteen such studies were included in the funding from the NBHW (Table 4 ). The research team was also involved in three additional studies funded by other sources. These studies focused on policy development in the Swedish Football Confederation, evaluation of regional collaboration against illegal alcohol, and alcohol prevention in Novgorod, Russia.

This set of studies included systematic collection of data from children, parents, and actors in projects. A description of the empirical studies carried out between autumn 2003 and spring 2009 is given in Table 5 . Different methods, including questionnaires, personal interviews, telephone interviews, and focus group interviews, have been used depending on the purpose of the study. The main research questions have been related to the process or effect evaluations of these projects. The majority of the studies have been carried out with adolescents, as many of the projects receiving grants from the NBHW are targeting adolescents for the purpose of preventing alcohol and tobacco use. In three studies, data have been collected from both adolescents and parents, and two of these are longitudinal studies with adolescents and their parents. Dyads of adolescents and parents are identified and have been followed over the three years of secondary school. All youth surveys have been carried out in a school environment while the questionnaires to the parents have been sent by mail. Municipalities, schools, and organizations across Sweden have participated in the studies. There are many advantages with the partnerships that have been developed between the research team and the project leaders within the NGOs. For example, the large scale of the studies that have been carried out during the six years could not been managed without this cooperation. The project leaders have done much of the practical work locally, such as the dialogue with participating schools and organizations, distribution of questionnaires, and sometimes also feedback to participants.

What types of research and development have been included?

All projects in the project portfolio had to submit semi-annual and annual reports. These reports were analysis and synthesized into an annual report to the NBHW. This was based on a reporting format using questions for different important elements in the projects as well as key aspects of project management. The preparation of the annual reports included cross-project comparisons with regard to the case study questions, which resulted in some amendments and changes over the years in the research and development activities.

After the decision on potential projects for in-depth studies, planning meetings were convened with the project leaders and managers in the NGOs. Based on the project proposals and joint planning between the project leaders and the researchers, a plan for the in-depth studies was developed. Depending on the evaluation and research questions and available resources the focus, design, process, and outcome measures were set (Table 6 ). The overall results were positive; ten of the fourteen in-depth studies were completed. One project did not succeed in recruiting high-risk parents to a parental support program (IOGT-NTO Centro). Three projects were only partially completed: one started before the research team was organized, making the evaluation impossible (IOGT-NTO: Dare/Young and King); one was cancelled after a decision by the municipality (SMART Västernorrland); and in one it was impossible to follow up information from policy-makers due to a low response rate (Makalösa föräldrar). Eleven of the in-depth studies started during the first period (Table 4 ). There were some common research questions such as the effects of the projects. The NGOs wanted their approach to be studied in such a way that, in the event of positive results, the program could be regarded as evidence-based.

Effect Studies

Seven projects were considered for evaluation with effect studies, which were planned for all seven projects. However, one project was unsuccessful and two only partially completed due to overly limited implementation. One project was already implemented when the research group was appointed. It was nevertheless possible to plan and successfully complete effect studies even with short-term yearly funding.

KSAN "About small things"

The aim of this project was to develop and test an early intervention targeting pregnant women to prevent alcohol injuries in unborn children. The project was developed by the KSAN, an umbrella organization for women's organizations concerned with alcohol and drug issues, and the Swedish Association of Midwives. It was implemented in a maternal health centre in Stockholm. A randomized controlled study was completed with 454 mothers randomly assigned to either receiving an information folder with the message "Pregnancy is not a time for risk-taking" sent to their home after the telephone contact for booking the first visit to the midwife, or getting the folder during their first visit to the midwife. The effects of the intervention were measured by a questionnaire that the pregnant women answered at the maternal health centre before they met with the midwife.

IOGT-NTO: Strong and Clear

Strong and Clear is a parental support program targeting parents with children aged 13-16 years. It is a universal program aiming to prevent drinking among adolescents and to maintain parents' restrictive attitudes concerning adolescents and alcohol. The program is manual based and includes thirteen activities during the three years of secondary school. The parents can sign up for the program during the whole period the program is carried out. There are both group and self-administered activities divided into four types: parent meetings, family dialogues, friend meetings, and family meetings. The program was implemented in six schools.

The research program includes the effect study, which was designed as a longitudinal quasi-experimental study, and studies of parental attitudes and behaviour with regard to adolescents and alcohol [ 78 ] as well as reasons for non-participation [ 73 ]. In the longitudinal study, 706 children and 613 parents participated in the baseline questionnaire, which was followed by repeated data collection in the two following school years.

IOGT-NTO: Parents Together

The program Parents Together consists of three parents' meetings during three years in secondary schools. The intention is to motivate the class parents to come to an agreement on the following issues: "We enforce the 18-year limit for alcohol; We will not provide each other's children alcohol; We will get in touch with each other if we see a child we know who is not sober, is behaving badly, or is out at times and places where we would not want our own children to be."This agreement is used to strengthen the cooperation among parents. The idea is that this will make a difference with respect to the children's alcohol use. A parent-teachers meeting is held each year to update the agreement.

The design of the study is a cluster randomized controlled study in Swedish secondary schools with seven intervention and six control school. The study included almost 2000 pupils and their parents. The program Parents Together was carried out over three years in the seven intervention schools with a start in both school years 7 and 8 (Figure 3 ). The six control schools have been offered the program for parents whose children are in year 7 in the spring 2009 and the program will follow in the years 2010 and 2011. To reveal effects of the program the evaluation also includes a questionnaire about the prevention work in schools and implementation reports. The non-governmental organization IOGT-NTO is responsible for the program and the implementation in the seven intervention schools. To maintain the cooperation between the thirteen schools, the NGO, and the research team, an agreement has been signed. The agreement includes information about the responsibilities of each party such as that the researchers should the results of surveys, within six months after the data collection, are published on the website.

Design of the intervention and evaluation of the program Parents Together .

IOGT-NTO Centro: Parental Support

This project was planned to include before and after questionnaires to high risk parents. However, the project did not succeed in attracting this type of parents to the program.

Hassela solidaritet: Peer Support in School

This NGO works with training and assisting school children to be peer supporters in their own school. The aims of the project are to prevent social exclusion by reducing teenage alcohol consumption, experimentation with drugs, and bullying through peer support in schools, and to promote a school that is a positive, creative, and stimulating workplace for all. The program was first implemented in one part of the school, and was planned to be extended to the whole school. Subsequent implementation in a second school was planned. However, this extended implementation was only partly carried out due to limited resources. The evaluation included focus group interviews with peer supporters and repeated cross-sectional questionnaires to schoolchildren in school years 7-9 in the two schools.

National Federation SMART: SMART Västernorrland

The main objective of this NGO is to prevent or postpone alcohol, tobacco, and other drug use among children through positive reinforcement and signing of contracts. The parents sign the contract together with their child. The content of these contracts varies between local organizations. The membership gives the child positive benefits reinforcing positive behaviours. The program was implemented in a Swedish county, Västernorrland. The evaluation plan included an effect study among schoolchildren in Kramfors, a study of parents, and an interview of stakeholders in the county. The program was cancelled by the municipality of Kramfors with negative consequences for the effect study, which had been planned as a repeated cross-sectional study of schoolchildren in years 4-9. Data was collected with questionnaires and during the three years, 2,052 children answered the questionnaire. The research team decided to implement the evaluation as planned even if there was no intervention the third year.

The Swedish Youth Temperance Movement (UNF): Folk Beer Project

The Non-governmental organization UNF is a politically and religiously independent organization. They are a sister organization to IOGT-NTO (The Swedish Temperance organization), which is a part of the International Organization of Good Templars. All members are between 13 and 25 years of age. To be a member you have to be a teetotaller. The activities are of different kinds, for example arranging theatrical performances, discos, cafés, study circles, and a large number of courses. Besides dealing with alcohol regulations and politics regarding alcohol, they also work with international exchange and democracy issues. Their vision is a democratic and socially responsible world free from drugs. Although they are politically independent, their task is to act politically in letting the politicians know which issues are important to them. UNF has an almost 40-year history of conducting underage alcohol purchase attempts.

In 2003 UNF applied for funding for a new idea. They wanted to compare two different strategies that included underage purchase attempts. The first was an elaboration of their earlier method, which meant confronting the media with the results of the purchase attempts, reporting the check-out clerks who sold them beer to the police, and informing the municipalities of which stores that sold beer to minors. The other method was based on the idea to actively seek cooperation with the retail grocery sector, the municipality's alcohol administrator or drug coordinator (the municipalities are organized differently), the police, and the labour unions. The evaluation program was designed as a quasi-experimental study and as a follow up of the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and of the effect of different strategies to influence the shops to comply with the law [ 74 ].

Studies of Process and Implementation

Seven of the in-depth studies focussed on the working process in the projects. Three projects were community-based and had a clear geographical area where the programs were implemented. Motgift Gotland was an alliance for preventing the use of narcotics on the island of Gotland. Söder mot Narkotika was also an alliance against narcotics in a central district (Södermalm) of the capital Stockholm. A broad range of agencies and organizations collaborated in these efforts. A third community-based project was run by Verdandi Tensta Rinkeby. The three community-based projects were studied during 2005-2006 and included interviews with stakeholders and actors in the projects. A lesson learned is that community-based prevention needs to have broad support and cannot depend heavily on individual project leaders.

Verdandi: Get safe in Tensta - Rinkeby. Meet us!

An in-depth analysis was made of the third project in order to uncover their successful strategy. Verdandi, founded in 1896, is a Swedish workers' organization striving for social justice and a society free from alcohol-related injuries. From the very beginning, Verdandi - as an independent organization within the workers' movement - has aimed to improve people's social and financial situations. Today's aim is to analyse the development of society through the experiences and voices of those who are not heard otherwise. People of all ages, in all parts of the country, may participate in Verdandi's activities, which are quite different from place to place since they are based on local needs. According to Verdandi, without a local angle, the organization would soon lose touch with reality as well as lose credibility and members.

Verdandi runs activities for youth. The project includes support for children both in school and after. The youth in the organization can use a facility in the neighbourhood in their leisure time. Youth activities have focused on "the young leading the young" and the project has demonstrated young people's ability to organize and run a rewarding activity in the evenings and on weekends. The aim of this prevention program is to empower young people in their daily lives and help them empower their friends. This, according to the organization, contributes to young people avoiding drugs, and the neighbourhood has become calmer and safer. The activity has a bottom-up nature and the youth are involved in the planning. They have the opportunity to develop activities and thereby affect their daily lives. Among the success factors, according to the in-depth study, are: confidence in the organization, equality, youth involvement and power, memberships, support from the parents, training of leaders, common norms and roles, volunteer work, easily accessible premises, and a leadership that facilitates democratic processes.

IOGT-NTO: Dare/Young and King

This program is a redesigned version of the American program DARE [ 79 ], which was implemented before the research group was appointed. However, an adult education component, Young and King, aiming to strengthen parents was implemented and a follow-up study was completed of this component of the program.

IOGT-NTO:s Juniorförbund: Junis sisters

In this project, groups of schoolgirls in years 5 and 6 are organized with the objective to strengthen their self-esteem and promote meaningful leisure activities and thereby delay the onset of alcohol consumption by the girls. The evaluation focused on the group leaders, who were interviewed in focus groups. A lesson learned is that special effort must be put into recruiting and assisting group leaders to achieve sustainable programs.

Makalösa föräldrar: Single Parent with Teenagers

The project consisted of two main parts. One part focused on improving the knowledge about how it is to be a single parent with a teenager in the family. A survey of single parents was done in a part of Stockholm and a small newsletter was produced. The other part included self-help groups for single parents and summer camps. The evaluation of the self-help groups consisted of follow-up questionnaires to participants. An unsuccessful part of the evaluation was the follow-up of the newsletter, which was well planned and properly designed. It was not possible to get feedback from policy-makers on the publication, which may be due to lack of awareness of the publication and its contents.

The Swedish Ice Hockey Association: School Ambassadors

The project aimed to train top athletes to become school ambassadors in order to influence the attitudes of schoolchildren and give them the opportunity to try out ice hockey. Moreover, the project was also an attempt to improve the collaboration between schools and top ice hockey clubs. In the second year the specialized ice hockey secondary schools were included in the program. The evaluation consisted of following up the training of the athletes and studying the work of the secondary school ice hockey players by means of a questionnaire to schoolchildren.

In order to promote the development of a partnership a series of measures were implemented (Table 7 ). All project leaders were invited to regular meetings, which were held in Örebro as well as in Stockholm, Gothenburg, and Malmö. The agenda included presentation of project plans, information from the NBHW, and the research and development activities by the research team. Thematic lectures and discussion on issues such as the art of project management, measures to reach target groups, media advocacy, Internet as a tool for prevention, and planned communication were held at different meetings. The main objective of these meetings was to promote exchange of experiences and learning in order to strengthening the quality of the implementation of the projects as well as networking. Moreover, the systematic bi-annual and annual reports were introduced and discussed.

Depending on the needs of the different projects special project dialogues and consultations were held between individual projects, or a small group of similar projects, and the research teams. The results of these meetings ranged from refinement of project ideas to long-term collaborations. All in-depth studies started with such meetings. The competence development took different forms. In the first period an academic training program in alcohol and drug prevention was offered to the project leaders, of whom about 10 participated. Supervision in groups was implemented in three groups during the first two years, and thereafter one or two groups were run by independent supervisors annually. During 2009 the research team arranged more project leader meeting including training in project management as an alternative to supervision.

The in-depth studies were also an important measure to foster the partnership between the NGOs and the research team. Due to available resources, more extensive process and effect evaluation activities could only be implemented in a limited number of projects. Many more projects asked to be the focus of in-depth studies than the fourteen that were initiated.

The research team together with the NBHW arranged a national conference Reflections on prevention - Collaboration for better alcohol and drug prevention. Conferences were arranged in the spring of 2006, 2008, and 2010. Among the key issues discussed at the first conference were the role of parents in prevention, adolescents, community-based approaches, and supply-reducing initiatives. The second conference also discussed the role of civil society and how to promote more effective cooperation among the different stakeholders. The third conference focussed on evidence and evidence-based practice, which have received increased attention in Sweden in many sectors of society. A main emphasis has been setting the context for reflection and sharing of experiences among the participants at the conferences; therefore a series of seminars with project presentations and panel discussions have been part of the conferences. Moreover, plenary sessions as well as theatrical performances further set the stage for professional dialogues on alcohol and drug prevention. The conferences have been well received and have attracted actors from different sectors of society as well as national agencies and NGOs.

In the annual reports the project leaders also assess the implemented measures by the researchers. These have guided the future efforts of the research team. As an example, the assessments made in January 2005 are presented in Figure 4 . The financial support was very important, followed by the support from the NBHW, the project leader meetings, and the supervision. One third of the project leaders regarded the support for the documentation as very important. The academic training in alcohol and drug prevention was regarded as very important by one fifth of the project leaders, which is a high proportion given that only a small group participated in the distance education course. Only eight projects were at that time included in the in-depth studies, nevertheless one third of the project leaders reported this measure as very important. The case study data bank includes information for questionnaires, interview and other data sources for the assessment of the implementation of the research strategy.

Assessment by project leaders of measures to improve collaboration between NGO and research in 2006 .

The research strategy has been successfully implemented despite the fact that only some projects were running more than one year while new projects and project leaders are included every year. The first two years a focus in the meetings with the project leaders was on the in-depth studies which were presented by the organisations and the researchers. Then the focus changed to addressing common concerns among the project leaders such as how to reach target groups, use of Internet, different type of prevention projects and mass communication skills. The presentations from the research teams were more concentrated to the national conferences that were organized bi-annually. The networking between the projects also resulted in new applications jointly by two organisations.

An important element was the relationship between the NBHW and the research team at Örebro University. During this period the NGO portfolio was managed at the NBHW by the same senior official. However, the department director changed three times during this period. The members of the working committee also changes over the years. The chairman was the same during all years. The support to the research and development activities was nevertheless maintained and also renewed for another year. The continuity with regard to persons seems to be very important for such an endeavour as included in this case study.

Discussion - towards practice-based research for alcohol and drug prevention

The integration of the research and development component into the support from the NBHW resulted in a unique possibility to do comparative studies involving, among other things, project management and implementation as well as project results. The measures to promote a partnership for practice-based research also improved the quality and success of the different projects. A few of the in-depth studies were unsuccessful due to factors hindering the implementation, and in several cases these factors were related to a lack of resources on the part of collaborating partners in the municipalities or other organizations.

The research strategy has been based on the overall aim to contribute to the evidence base for alcohol and drug prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. The current development of practice-based research will give more relevant knowledge and our research program attempts to be a part of this trend. Moreover, the utilization of research results may also be improved if studies on efficacy, effectiveness, and dissemination are promoted [ 18 ]. The strategy that the NBHW developed in this program of governmental support to NGOs was an attempt to bridge this gap as described by Nutbeam [ 10 , 11 ]. This challenge for agencies to respond to the push from the funders and pull from the communities has been noted by Green and Mercier [ 23 ] and the public health researcher also needs to leave the university campus to get involved in more practice-based research. Our research program has developed along such lines.

The research strategy includes the use of qualitative, quantitative, and mixed methods. This means that data collection and data analysis are done using guidelines for these three traditions. The challenge is most apparent with regard to inference and integration. In the stages of inference in a study, quality issues such as internal and external validity in the quantitative approach and aspects of credibility, confirmability, and transferability in the qualitative approach are pertinent. Integration is the mixed-methods approach of working across strands and using meta-inferential issues related to the integration of findings and inferences from the two strands. Here design quality, interpretative rigour, and inference transferability have been proposed as indicators of quality [ 70 ]. In this research strategy case study, the set of research entities changed each year due to the funding of applications from NGOs by the NBHW. The present study covered a six-year period, and the stages of inference and integration were completed yearly in the preparation of the annual reports to the NBHW.

The research strategy also includes elements of participatory research. The organizations were involved in developing the main research questions in the in-depth studies. Sometimes the organizations also assisted in collecting questionnaires from school children; in making participatory observations, as in the studies of beer purchasing by minors; or in providing feedback to school staff and target groups, as in the parental support programs. Moreover, the organizations also played a role in discussing preliminary results as part of a validating process for the empirical studies. These discussions never changed the interpretations of the findings but often gave more insight into the noble art of implementation of preventive programs. Nevertheless, as in other research programs, a number of methodological challenges had to be dealt with. The resources were limited, which gave room for only a small number of in-depth studies. Therefore the research strategy included additional elements such as support to documentation as well as support to the project leaders in meetings and management training. The selection of these studies was mainly done by the steering committee at the NBHW. The research team developed a proper design for these studies based on the assessed potential for a successful implementation and possible options given the resources available for effect or process studies. Then the choice of methods for data collections was reviewed and target groups for the evaluation research selected. In this process the best choice from an academic point of view was often not possible due to limited staff and other resources. Nevertheless, the research program resulted in data collected from 9,568 children, 4,832 parents and 327 actors or stakeholders. Moreover, it was possible to carry out two large longitudinal studies of children and their parents in this research program. Even if the funding was granted annually, it was possible to think and plan on more long-term basis.

A broad range of organizations received project funding from the NBHW. Although the largest number of projects was run by the nine alcohol and drug organizations, the alcohol and drug prevention was successfully integrated into a range of organizations with other main objectives. Moreover, the project leaders also came from different societal sectors. This was an intended effect of the governmental initiative to strengthen the alcohol and drug prevention in Sweden. This led to another methodological challenge caused by the fact that the programs were so different. The research team developed questionnaires with common modules that could be used in different evaluations thus giving them access to data from schoolchildren and parents in different contexts and programs. This made it possible, for instance, to study the reasons for non-participation in parental support programs [ 73 ]. Another added value related to this was the possibility to organize a study of project management through a special study of the project leaders, which was integrated into the overall design of the support from the NBHW.

A challenge for the research team was that the funding for the research as well as for the alcohol and drug projects was decided annually by the NBHW. However, the research was planned with a longer time period in mind, which has actually led to a research program that has been running more than six years. A more long-term grant would have been beneficial for the development of a partnership between the NGOs and the research team. In order to overcome this barrier a multi-year agreement has been signed for the newer in-depth studies, but it was still signed on the condition of renewed funding the following year. Nevertheless, a trustful partnership was developed between all three partners: the practitioners in the NGOs, the national agencies, and the researchers. In many cases the planning and implementation were done jointly, dividing the responsibilities according to skills and keeping the roles clear and feasible to complete successfully. The validity of the results was also a major concern as well as an emphasis on a participatory approach to the research process.

Ethical concerns were very important, as stipulated by Swedish law. The effect studies were assessed by the regional research ethics boards. However, it is also important to analyse if the NGOs have vested interests in the research process. Government agencies as well as NGOs can also have a vested interest in scientific research, such as when science is misused to benefit a particular political agenda, ideology, or favoured interest group [ 80 ]. However, the problem of vested interests is more dangerous when key parts of the government sector are in conflict over their public health responsibilities; for instance health sector engagement in partnership arrangements with addictive consumption industries (particularly alcohol, tobacco, and gambling) entails too many risks [ 81 ]. In our case there have been shared visions and objectives between the government agency and the NGOs, which guided the developmental activities as well as the research work. Moreover, the division of responsibilities between the NGOs and the researcher was important. The NGOs had the responsibility for developing the proposals, conducting the interventions, and implementing the preventive programs or initiatives. The researchers had the responsibility for planning the effect evaluations after consulting with representatives of the NGOs, as well as for implementing the research components, analysis, and reporting of results, including dialogues about the outcomes, and presenting the findings for the NGOs.

The organization of the research program under the auspices of public health science at Örebro University was natural as the principal investigator holds a professorial chair in public health there. During the first two years, other members of the research group were formally employed by an NGO but worked at the university campus in Örebro. All members of the research team were subsequently offered employment at the university, giving the research team a formal independence from all NGOs.

The addiction research centres have mandates that are broader than the present research program. The centre in Michigan has the mission to develop new knowledge about the cause, course, and consequences of substance use disorder and to train the next generation of researchers [ 28 ]; and the Canadian centre in British Columbia to create an internationally recognized centre distributed across BC that is dedicated to research and knowledge exchange on substance use, harm reduction, and addiction [ 27 ]. The Swiss institute is primarily involved in collecting alcohol-related information and making it available to professionals and the general public. The Swiss Institute will continue to monitor substance use, while stepping up its prevention research activities and ensuring that it is able to react promptly to emerging phenomena [ 25 ]. Our small research team is attempting to fill a gap in knowledge about the NGO alcohol and drug prevention efforts as these offer unique opportunities [ 82 ].

The research strategy was successful in establishing prevention research for alcohol and drug prevention by NGOs, which previously had been lacking in Sweden. Moreover, added value came from having meetings for project leaders, and the capacity building led to new innovative collaboration between different NGOs, which resulted in new applications for funding and successful implementation of new initiatives. The administrative support for improving the documentation of the implementation and progress of the projects was also recognized as beneficial for the practitioners and the national agency as well as the researchers. The best approach is always transparency and discussion, disclosure and debate [ 83 , 84 ].

A weakness in the research strategy was that the funding was not sufficient for more than a limited number of in-depth studies. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. It was beneficial because it gave the research team opportunities to address other issues. From a strictly research point of view it would have been of interest to see what could be achieved by researchers-as-designer , but this would have been very costly and all funds allocated to the integrated research activities would have been consumed by just one project. In other words, the present research strategy can be regarded as cost-effective.

The overall strategy for research and development includes capacity building for both the practitioners in the NGOs and the research team, and two doctoral dissertations will be finalized during the coming year. The NBHW has also noted that, given the limited duration of funding, this organization of knowledge development - as an integral part of the support to NGOs - is beneficial, which is indicated by the annual renewal of the contract with Örebro University. Moreover, the much more extensively funded projects in municipalities, regions, and counties still lack this strategic element. At present there is a trend that some larger governmental grants are given to such parties, but a mandatory linkage to universities for research is included in the call for proposals. This could lead to similar forms of trustful partnerships as found in the present research strategy case study.

The in-depth studies in this research strategy varied in content, design, and size. A common element was that they were program-driven and not research-driven interventions [ 9 ]. This may give the studies improved external validity [ 54 ]. The research strategy aimed at improving the evidence-base for alcohol and drug prevention. In our case this has meant using qualitative, quantitative, and mixed methods, as well a variety of designs to answer questions in practice-based settings. Including feedback and dialogue with the NGOs has further contributed to sustainable AD prevention in different settings. The missions of the NGOs differ, but the AD prevention has been included as an essential part of their activities, which in many cases meant that AD prevention has received increased priority. Moreover, the integrated research program has also been seen as beneficial and important for the organizations, which often wanted their programs to be recognized as evidence-based. Therefore, the demand for research by the NGOs is larger than what we can supply at present. This is a challenge to the funding agencies as well as research bodies. The addiction research centres seem to nurture creativity but often lack the networks and priorities for preventive research. It is important to go beyond the notion that a lack of evidence for a program is necessarily a sign of a lack of effectiveness. Therefore, practice-based research and collaboration between decision-makers, national agencies, NGOs, local authorities and researchers is needed. Using a combination of different and interactive measures it was possible to over the years built a trustful partnership between these parts. This research strategy case study shows that it is possible even in such a dynamic field as alcohol and drug prevention in NGOs where the organisations are competing for grants from the NBHW. There are added values in supporting a research group assigned to a project portfolio instead of having a series of smaller independent evaluations.

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organizations. Competence development is necessary for developing evidence for policy and practice. Given research groups assignments to address the knowledge development issues is better than having minor evaluation in individual projects. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

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Acknowledgements

The authors are very grateful to all the NGOs that have shared their efforts and experiences with the research team. We would also like to acknowledge Åke Setréus for his support and encouragement during the whole period. The Swedish National Board of Health and Welfare supported the study.

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The four authors of the manuscript are presented in alphabetical order and their shares of the responsibility for the paper are equal. CE is the principal investigator for the research program integrated in the NBHW support to NGOs for alcohol and drug prevention. CE, ML, and CP were involved in all aspects of the program as well as this study. SG was involved in the planning, project implementation, and writing of the section on NGOs. All authors read and approved the final manuscript.

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Eriksson, C., Geidne, S., Larsson, M. et al. A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009. Subst Abuse Treat Prev Policy 6 , 8 (2011). https://doi.org/10.1186/1747-597X-6-8

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The Past and Future of Research on Treatment of Alcohol Dependence

Research on the treatment of alcoholism has gained significant ground over the past 40 years. Studies such as the National Institute on Alcohol Abuse and Alcoholism’s Project MATCH, which examined the prospect of tailoring treatments for particular people to better suit their needs, and Project COMBINE, which examined in-depth, cognitive–behavioral therapy and medical management, helped pave the way for a new way of approaching alcoholism treatment. New findings garnered through the National Epidemiologic Survey on Alcohol and Related Conditions further defined the problem. At the heart of this research has been the development of procedures to characterize, measure, and monitor the fidelity to a particular conceptual psychotherapeutic approach so that clear comparisons can be made between conceptually and technically distinct approaches. Advances in scientific methodology and statistics have provided tools to analyze complex datasets. The resulting findings mark an improvement over the first models of treatment developed decades ago, which tended to focus on anecdotal findings and assumptions. This hard-earned progress has enabled scientists today to move ahead and address the next set of challenges. Future research, coupled with a restructured treatment system capable of making new scientific findings rapidly available to the community, hold the key to significantly improving treatment outcomes and reducing suffering from alcohol-related disorders.

Remarkable progress has been made in the treatment of alcohol use disorders (AUDs) over the past 40 years. We have a better understanding of the natural history of heavy drinking and the development of dependence. We understand better the course of recovery and the risk factors and prognostic indicators for AUDs. Most importantly, we have made significant strides in the behavioral and pharmacological treatments available to people, and their families, who suffer from alcoholism. Research supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has been instrumental in advancing treatment, moving our understanding from anecdotal approaches to those that are based firmly on evidence.

Of course, new scientific findings almost always generate more questions than they resolve, and alcohol treatment research is no different. Research conducted over the past four decades has created a number of new scientific challenges. The most central of these challenges is to truly understand the scientific basis underlying health behavior, such as alcohol consumption. This calls for careful understanding of behavior and the steps involved in decisionmaking, as well as the social determinants that influence those decisions; in short, we need to know who we are and why we do what we do. It is especially important to identify potentially modifiable operators within the systems that determine these behaviors in order to develop new and more powerful ways to help people overcome addiction to alcohol. Medications offer one method to do so, which will require identifying neurophysiological and genomic targets for development of new medications with novel mechanisms ( Koob 2006 ). Better-targeted behavioral approaches that address these habits (such as addiction) also are needed. Ultimately, our goals are to ensure that more people respond to treatment and that they are able to experience long-lasting effects from that treatment.

In addition to addressing these scientific challenges, there is a pressing need to create a new system of providing risk reduction and treatment for heavy drinkers and people with alcohol dependence. The current treatment system model, the Minnesota Model, was developed by professionals at a State hospital in Minnesota and promulgated most famously by the Johnson Institute and the Hazelden Foundation. Based on what was known at the time (primarily through the folk wisdom of Alcoholics Anonymous [AA]), the Minnesota Model combined the first five steps of AA with lectures on the disease concept of alcoholism and some practical supportive psychotherapy. Central to its concept was the use of staff members who themselves were in recovery from alcohol dependence, along with others ( Anderson et al. 1999 ).

Unfortunately, because this model of care was developed without the benefit of a scientific basis, it was not configured in such a way as to rapidly change in response to scientific advances. Currently, more than 90 percent of community treatment programs in the United States offer lectures, group counseling, and referral to AA, and nothing else ( McLellan and Meyers 2004 ). It is common that treatment staff members are poorly trained and supervised, are paid little, and frequently do not stay long ( McLellan et al. 2004 ). In fact, the “counseling” that is provided often consists of casual talk rather than sophisticated psychotherapy ( Carroll et al. 2008 ). To assert this is not to disparage the dedicated professionals who devote their lives to helping others with addiction. However, most addiction counselors have relatively little education and almost no supervision, which is in stark contrast to the counselors who provide behavioral treatment in efficacy trials ( Anton et al. 2006 ; McLellan and Meyers 2004 ). In addition, very few treatment programs use integrated teams with other professionals such as physicians, psychologists, nurses, and social workers ( McLellan and Meyers 2004 ). As a result, there is a disconnect between what has been discovered through research and what is actually implemented in everyday practice, or, for that matter, what can be implemented given the state of the treatment system.

Challenging Current Treatment Models

The first decades of research on treatment of alcohol dependence were characterized by several assumptions: (1) that change occurred because of, or was substantially influenced by, interaction between a client or patient and a professional—in a word, psychotherapy; (2) that the technical differences between different psychotherapeutic approaches would result in different outcomes, or at least different outcomes for different patients; (3) that most people with alcohol dependence had severe, recurrent, or chronic dependence; (4) that change depended on the development of insight and the conscious application of techniques or methods taught by an expert (who in this case would include an experienced AA member, such as a sponsor); and (5) perhaps most importantly, that the problem to be addressed was alcoholism, not heavy drinking, which were considered to be quite different entities.

For the most part, these assumptions have been proven wrong, or at best incomplete. About three-quarters of people with alcohol dependence reduce or stop drinking without any kind of professional treatment or even interaction with a community support group such as AA ( Dawson et al. 2005 ). Psychotherapies that are conceptually and technically distinct have very similar results ( Project MATCH Research Group 1998 ). Almost 70 percent of people who develop alcohol dependence have mild-to-moderate forms that are self-limiting ( Hasin and Stinson 2007 ; Moss et al. 2007 ). Although some differences in therapist technique, such as use of an empathic, engaging approach, are associated with marginally better outcomes ( Miller and Rollnick 2002 ), it still is unclear what drives change. Finally, there is no clear distinction between heavy drinking, per se, and “addiction.” In fact, non-symptomatic heavy drinking blends imperceptibly into mild then moderate dependence and, in a minority of those affected, severe and recurrent dependence. Alcohol dependence is not inevitably progressive but may have long periods of stability or alternate back and forth between heavy and lighter drinking and abstinence ( Dawson and Grant 2006 ; Dawson et al. 2005 ; Vaillant 2003 ).

Many of these conclusions, however counterintuitive they may seem, are the result of rigorous research by a dedicated scientific community. At the heart of this research was the development of procedures to characterize, measure, and monitor the fidelity to a particular conceptual psychotherapeutic approach so that clear comparisons could be made between conceptually and technically distinct approaches. Advances in scientific methodology and statistics also have provided tools to analyze complex datasets. This hard-earned progress has enabled scientists today to move ahead and address the next set of challenges.

For example, NIAAA’s Project MATCH compared three different approaches: cognitive–behavioral, which focuses on teaching skills such as drink refusal and relapse prevention; motivational enhancement, which focuses more on addressing ambivalence about and motivation to change; and 12-step facilitation, which focuses on teaching that alcoholism is a disease that requires abstinence and affiliation with AA ( Project MATCH Research Group 1998 ). In addition, 20 different hypotheses were proffered concerning interactions between study participant characteristics and the specific therapy approach—that is, that participants with certain characteristics, such as antisocial traits or anger, would respond differentially to different therapies.

The result, for the most part, showed that all three groups had highly similar (and positive) results, and most matching hypotheses were not supported ( Project MATCH Research Group 1998 ). Far from a failure, however, this outcome showed that treatment works. Unfortunately, no attribution could be made as to what caused these positive outcomes, because all three therapeutic approaches had similar outcomes. Perhaps the most significant outcome was that Project MATCH provided a formidable challenge to existing thinking. Technical differences between therapies did not seem to result in different outcomes, even for extremely well-characterized participants across multiple domains. In addition, although it was not recognized at the time, it also provided a clue as to where scientists might look next. The concept emerging from the Project MATCH study (and many other studies with similar outcomes) was this: If technical differences among therapies (such as cognitive–behavioral therapy, motivational enhancement therapy, and 12-step facilitation therapy) do not account for differences in change, then it is unclear what indeed is driving the large change that occurs in most people who seek treatment.

Understanding the Mechanisms of Change

Looking carefully at treatment studies for alcohol dependence, some interesting features emerge. First, the results of these studies are remarkably similar. Studies comparing different behavioral approaches, placebo-controlled medication trials, and studies combining the two have essentially identical average baseline and 12-month outcomes ( Anton et al. 2006 ; Project MATCH Research Group 1998 ; Miller et al. 2001 ).

Overall, treatment outcomes are much better than might be expected given the widespread pessimism about outcomes. For example, about one-third of people who enter treatment trials are in full remission from alcohol dependence for the following year, and the other two-thirds show substantial improvement, from an average of more than 70 drinks per week to less than 10 drinks per week ( Miller et al. 2001 ). Nevertheless, the specific treatment received (as long as it is high quality, which is the case in research studies comparing treatments) does not seem to account for differences in outcomes.

These findings suggest that positive change is either a part of the natural history of the illness or the result of nonspecific factors, such as installation of hope, the decision to change, and encountering an empathic therapist who is willing to help and who has a way to do so. Conceptually and technically distinct forms of psychotherapy have roughly equivalent outcomes if they all are provided by trained professionals who are screened for the ability to form an empathic relationship with their clients ( Project MATCH Research Group 1998 ). Certain medications, such as naltrexone and topiramate, also provide meaningful improvements in outcomes, compared with placebo, but those differences pale in comparison to the overall improvement in both groups.

One interpretation of these findings is that the change process may be driven more by nontreatment factors than treatment-specific factors, or at least factors other than specific technical differences among therapies. Recent reanalyses of several clinical trials have examined the course of drinking among study participants before entering the trial, based on retrospective accounts obtained during the baseline evaluation. It appears that for most study participants the change process began before entering treatment, often by weeks ( Penberthy et al. 2007 ), and often includes stopping or nearly stopping drinking prior to study entry. Thus, treatment entry may be a result of change rather than an instigator of it.

Perhaps the decision to enter treatment is the crucial change point. A qualitative study of participants’ accounts of what occurred in their lives prior to study entry strongly suggests this is the case (Orford et al. 2005). Participants described a process of increasing distress and drinking and pressure from others to change. Then a trigger event, such as a drunk driving charge or domestic disturbance, led to a realization that “I can’t do this alone,” which, in turn, led to the decision to seek help. In addition, as the participants continued through the treatment process, many non-treatment factors were highly influential in what course they took. These nontreatment factors often are ignored in treatment research, when in fact they may be responsible for a much greater proportion of change processes than treatment. An additional concern is that most efficacy trials exclude many people who need treatment but do not meet rigorous inclusion and exclusion criteria, raising questions about how applicable the results of these studies are to community clinical populations ( Humphreys et al. 2005 ).

Taken together, these and other findings provide evidence that many of the assumptions underpinning the previous several decades of treatment research were wrong or at least incomplete. The mechanisms of change in drinking behavior among heavy drinkers are not well understood. In addition to these findings regarding treatment studies, it recently has become clear that most people with alcohol dependence change without exposure to treatment or AA ( Dawson et al. 2005 ; Fein and Landman 2005 ; Moss et al. 2007 ). Thus, the mechanisms of change for these individuals are not well characterized or understood and more attention needs to be paid to change outside the context of professional treatment or AA. Additionally, future research needs to focus on elucidating the actual mechanisms of change and how treatment professionals can best assist people in reducing or eliminating heavy drinking.

None of this is meant to suggest that providing treatment for people with alcohol dependence is either unnecessary or ineffective. Rather, progress in treatment research has raised important questions about how to improve already-decent outcomes for people seeking treatment. In addition, even though the majority of people with alcohol dependence have mild-to-moderate, rather than severe, dependence, they still require treatment to decrease the impact on those affected and to shorten the course. This is not significantly different from many other medical disorders. For example, most depressive episodes are ultimately self-limiting, but untreated they may result in substantial disability and misery ( O’Leary et al. 2010 ). The same could be said of asthma or arthritis. Another important goal is to provide treatments that are acceptable and accessible earlier in the course of illness rather than waiting until chronicity and severe disability already are present.

In 2005, NIAAA began to alter the direction of research funding concerning changes in drinking behavior. Staff of the Division of Treatment and Recovery Research branch first held a series of informal meetings among senior investigators representing a wide variety of scientific disciplines, including many with no prior experience in alcohol treatment research. The perspective outlined above was presented to them and they were asked to suggest possible new directions for behavior change research. Following those meetings, a strategic research plan was developed and presented to the Extramural Advisory Board, a subcommittee of the NIAAA National Advisory Council. After further discussion and refinement, the plan was approved by the Advisory Council and the NIAAA Director and was incorporated into the NIAAA Strategic Plan (see www.niaaa.nih.gov ).

What emerged was the NIAAA Mechanisms of Behavior Change (MOBC) Initiative. This initiative is an ambitious plan to fund interdisciplinary high-risk research projects and has the potential to transform our understanding of change in drinking behavior among heavy drinkers. One senior scientist, Dr. Jon Morgenstern, participating in the process described the goal as “developing the basic science of behavior change.” In this context, however, basic science refers not only to wet-lab basic research but also behavioral, psychological, and social components, which are essential to understanding the complexity of behavior. There is no “bottom-up” assumption that the “real” determinants are genomic or neurophysiological, because influence from one level to another is bidirectional: each level of analysis (genomic, cellular, physiological, individual, and social) influences all the others in a dynamic interplay. This entire system often is described as a complex dynamical system ( Barabasi 2009 ). In a complex dynamical system, the whole is more than the sum of its parts. One systems theorist ( Barabasi 2009 ) used the analogy that it is possible to know and be able to lay out every single part of an airplane, but that tells you nothing about how an airplane flies or how a particular airplane will respond to wind shear. With this in mind, NIAAA invited experts in the mathematical modeling of complex systems to participate in the initiative and they, in turn, have played a crucial role in shaping its direction and focus.

The NIAAA MOBC Initiative has stimulated several new lines of research. This research is in its earliest stages and it may take some time before results are obtained and even longer before clinically useful tools are developed as a result. Yet significant progress is being made. In the past 2 years, a cross–National Institutes of Health (NIH)-MOBC Initiative involving more than 15 NIH Institutes and Centers has developed and momentum continues to grow. In February 2010, NIH issued an NIH Roadmap request for applications on the science of behavior change, providing additional evidence of a sustained commitment to MOBC research.

Reconfiguring the Treatment System

No matter how elegant the research is and no matter how powerful the new treatments are that emerge from it, those findings must be accessible. For the most part, the scientific advances of the last 40 years have not been well embraced by treatment providers. Very few people with alcohol dependence seek or receive any kind of professional treatment ( Moss et al. 2007 ). Effective medications are prescribed very infrequently ( Mark et al. 2003 ). The model on which most currently available treatment relies was developed about 50 years ago, when scientific understanding of substance use disorders was rudimentary ( Anderson et al. 1999 ). More than 90 percent of U.S. treatment programs currently offer group counseling and referral to AA, without access to medications or evidence-based behavioral treatment ( McLellan and Meyers 2004 ). As a result, most consumers have little choice as to what treatment they wish to receive. Many counselors have minimal training, and the turnover among treatment program staff is more than 50 percent annually ( McLellan and Meyers 2004 ). There is a constant shortfall of funding so programs are unable to invest in infrastructure such as electronic medical records ( McLellan and Meyers 2004 ). Although program staff members often are dedicated and hard working, this environment makes providing modern treatment extremely challenging if not impossible.

Perhaps more importantly, most treatment programs are predicated on the idea that a relatively brief period of education and counseling will lead to a major shift in the trajectory of a serious chronic illness, an approach that has no scientific basis and which is not used for other chronic disorders. It is true that some types of psychotherapy for psychiatric disorders may be given in a time-limited way, but this generally occurs in the context of ongoing care management by a mental health or primary-care clinician. In addition, multiple courses of the same therapy usually are not prescribed when a disorder proves resistant to the first full course of well-administered therapy. For alcohol dependence, however, patients often undergo multiple courses of rehabilitation even when it is completely ineffective for a particular person simply because no alternatives are available.

A final important limitation of the current system is that it is focuses on the most severely affected people—those with severe and persistent alcohol dependence—most of whom have encountered serious life consequences. It is not configured to provide care to people with milder forms of dependence. That group, which comprises nearly three-fourths of all cases, typically remains functional and almost all eventually enter full remission ( Moss et al. 2007 ). Thus, the current treatment system reaches relatively few people with dependence, provides time-limited counseling for people with severe and persistent dependence, fails to offer consumers a choice of treatment approaches, and is not configured to deliver new approaches based on research. It is time to broadly reconsider what kind of services should be offered, where they should be offered, and who should provide them. Fortunately, 40 years of research provides a solid scientific basis to guide this process and suggests a framework for moving forward.

Building a Scientifically Based Continuum of Care

There is a broad spectrum of drinking behaviors and associated risk of alcohol-related problems spread across the entire adult population, as determined by the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) ( Grant et al. 2004 ; Hasin et al. 2007 ). NIAAA guidelines recommend that healthy adult men drink no more than 4 U.S. standard drinks in any day and no more than 14 drinks in any week and that healthy women drink no more than 3 drinks in any day and no more than 7 drinks in any week (NIAAA 2009). A standard drink in the United States contains about 14 g absolute ethyl alcohol by volume, the amount in 1.5 oz of 80-proof spirits, about 12 oz of beer, or about 5 oz of table wine. (Note that drink sizes vary widely by culture. For example in Australia and the United Kingdom, a standard drink “unit” contains about 10 g absolute alcohol by volume, the amount in 30 cc of 80-proof spirits.) Also, to be considered within the guidelines, both the daily and the weekly limits apply. Thus, someone drinking three drinks every day would not fall within these limits, nor would someone who drank eight drinks on 1 day in a week. Individuals who drink above the guidelines but who do not report having problems or symptoms related to drinking are considered to be at an elevated risk for developing consequences in the future. These “at-risk” drinkers are analogous to someone with high cholesterol but who has not yet developed coronary artery disease. Once several symptoms have developed (currently three for dependence and one for abuse), the individual is considered to have an AUD.

Thus, there are basically three groups of drinkers: people who never exceed the guidelines; at-risk drinkers who exceed the guidelines but have no current symptoms and who have never had alcohol dependence; and people with symptoms or consequences related to their drinking who thus can be diagnosed with an AUD. Currently, the diagnostic criteria for an AUD are based on the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual, Fourth Edition, Text Revision ( DSM–IV–TR; APA 2000 ). The criteria have been undergoing review and revision for the fifth edition and are expected to be released in 2013. In the recently published draft guidelines, the categories of abuse and dependence are no longer separate disorders. Instead, the criteria for abuse and dependence have been combined in a single AUD. This revision is based on research demonstrating that the abuse and dependence diagnoses did not work as expected and that a single-dimensional construct offered a simpler solution that better fit the research findings. Thus, in the remainder of this paper, the term AUD will be used to describe what are now two different diagnoses.

In U.S. adults in any given year, 70 percent never exceed the NIAAA guidelines, either because they abstain or they drink within low-risk limits ( Hasin et al. 2007 ). Of the remaining 30 percent, most (21 percent) are at-risk drinkers and 4 percent have an AUD ( Hasin et al. 2007 ), currently diagnosed according to DSM–IV–TR as alcohol dependent. Among the 4 percent with dependence, 3 percent have functional dependence and 1 percent has severe recurrent or chronic dependence ( Hasin et al. 2007 ).

Functional alcohol dependence can be described in this way: Individuals repeatedly drink more or longer than they intend to, have a persistent desire to quit or cut down and have difficulty doing so, may drink and drive (without receiving a driving-while-intoxicated [DWI] citation), and often continue drinking in spite of physical or psychological symptoms such as hangover, headache, poor sleep, or nausea. Most people who develop an AUD have only three or four symptoms and do not develop severe life disruption as a result of their drinking. For example, they do not miss work, neglect their children or other responsibilities, have legal trouble, or lose their jobs. In many cases, only their closest friends and family members realize that their drinking is out of control. In addition, a striking and unexpected finding from NESARC is that 72 percent of people who develop alcohol dependence in their lives have a single episode lasting 3 to 4 years on average, after which it goes away and does not recur ( Hasin et al. 2007 ). The 28 percent who have recurrences have an average of five episodes ( Hasin et al. 2007 ). Thus, there appear to be two forms of this disorder, a milder self-limited form and a more severe recurrent form.

This new understanding differs drastically from what was traditionally described as alcoholism, a chronic, severe, progressive disease. This new insight was developed in part from NESARC findings. NESARC studied the general population and identified individuals who had gone through a period of years struggling with drinking too much but who eventually overcame it without seeking professional help or AA. This finding was in contrast to previous research efforts, which generalized to everyone findings from people in treatment programs or AA. As a result, researchers mistakenly assumed that unidentified “cases” in the community were similar to those in treatment, but that clearly is not the case. The same holds for every other medical disorder. For example, for people who have asthma, influenza, or depression, only a small proportion ever require hospital care, and it is because they have a milder, more treatment-responsive or less complex form of the illness. It turns out that the same is true for AUDs.

The result, then, is four distinct groups: abstainers and low-risk drinkers, at-risk or high-risk drinkers, people with functional alcohol dependence, and people with severe recurrent alcohol dependence. This new grouping, based on a large epidemiological research dataset, provides scientists with the information they need to devise a continuum of care for each group.

For abstainers and low-risk drinkers, the goal is to prevent a problem from developing, especially, but not exclusively, in young people. Universal prevention usually occurs in settings such as schools, workplaces, and health care settings. Such measures include public awareness campaigns establishing healthy limits and requirements for beverage labeling (Miller 2004). Such approaches provide consumers with the information they need to make informed decisions. A current example is the intense public health focus on overeating and obesity.

To support healthy choices in alcohol use, NIAAA recently published a consumer-oriented booklet and accompanying Web site (“Rethinking Drinking”) with information on defining a “standard” drink, recommended limits for alcohol use, and tips for cutting down on drinking. This material, though not expected to directly affect behavior change, may indirectly influence drinking behavior by supporting efforts to reduce drinking within the community at large. Studies to have not yet determined the efficacy of this approach.

For at-risk drinkers who do not have an AUD, the goal is to reduce the risk of later development of downstream consequences of heavy drinking. At-risk drinkers are similar to people with high blood pressure but who do not have symptoms or a cigarette smoker without lung cancer or heart disease. Fortunately, at-risk drinkers respond well to a variety of low-intensity interventions, including brief counseling by a physician ( Whitlock et al. 2004 ) and Internet-based approaches such as “Rethinking Drinking.” Although it has not been well studied, it is likely that work-place initiatives, toll-free telephone numbers, and other low-cost high-yield methods also will be successful in treating at-risk drinkers. There is some evidence that the medication, naltrexone, may be effective in this group as well, as most at-risk drinkers prefer to cut down rather than quit. Naltrexone reduces the “buzz” one gets from drinking and thus makes it easier to drink less ( O’Malley 1998 ; Volpicelli et al 1992 ).

Individuals with functional AUDs seldom, if ever, go to AA or an addiction treatment program, simply because they are able to manage their lives and not get into serious trouble even though they are drinking more than they wish ( Hasin et al. 2007 ). Onset varies from late teens to older age. Most seek no help at all and yet eventually are able to overcome their compulsive drinking either through abstaining or cutting back to low-risk drinking ( Moss et al. 2007 ). They typically suffer, however, for a period of years, and, although their lives do not fall apart, their excessive drinking may be a matter of significant concern for them and their loved ones. In this way, people with functional AUDs resemble others with major depression or anxiety disorders who are able to function but at a suboptimal level and with a significant level of distress. In both cases, effective medication treatment is available that can be prescribed by a physician. In the past, people with depression were rarely treated. Like AUDs now, only the most severely affected were identified and treated, typically with hospitalization. In 1987, when Prozac ® was introduced it changed the treatment landscape significantly. Now with many similar effective, safe, and easy-to-use medications available for treating depression, more than two-thirds of people receive treatment, usually from their primary-care doctor ( Ledoux et al. 2009 ). Only the most complex or treatment-resistant cases are referred to psychiatrists.

It is not widely known that medications currently are available to treat alcohol dependence and which have similar effectiveness to modern antidepressants (Bouza et al. 2005; Johnson 2007 ; Mann et al. 2004 ). Naltrexone and topiramate both reduce relapse in early abstinence patients by 20 to 30 percent, resulting in more people attaining sustained periods of abstinence compared with people taking placebo (Bouza et al. 2005; Johnson 2007 ; Johnson et al. 2003 ; Mann et al. 2004 ). A much older drug, disulfiram, is effective if used properly to ensure adherence ( O’Farrell et al. 1995 ), and it has the advantage of being very inexpensive. Several other medications have some evidence of effectiveness and many more are in various stages of development ( Johnson 2007 ; Srisurapanont and Jarusuraisin 2005 ). These medications are ideal for treating large numbers of people with functional AUDs in a discrete, familiar setting, such as the family doctor’s office. Coupled with brief support directed at encouraging medication adherence, attendance at community support groups, and abstinence, these medications are as effective as state-of-the-art behavioral treatment, at least among people seeking help for their drinking.

Thus, effective therapies exist for people with mild-to-moderate severity AUDs, who currently do not receive any treatment at all and for whom traditional rehabilitation programs, which better address a much smaller group of people with severe chronic AUDs, are not appropriate. For those who would prefer psychotherapy to medication, several behavioral approaches are effective in outpatient settings ( Miller et al. 2001 ), including cognitive–behavioral treatment, motivational enhancement therapy, community reinforcement, and 12-step facilitation ( Project MATCH Research Group 1998 ; Smith and Myers 2004 ). Emerging research also suggests that computer-based behavioral approaches (especially cognitive–behavioral treatment) may be effective either as a substitute for or augmentation of person-to-person treatment ( Carroll et al. 2008 ). It is likely that various combinations of computer-based and personal behavioral treatments will emerge, further increasing the options available to people who need help.

At the other end of the spectrum are those with more severe recurrent AUDs. These individuals are more likely to have a strong family history of AUDs, to have behavioral problems as children and antisocial behavior as adults, to come from chaotic families, and to experience the onset of AUDs in the early to mid-teens ( Moss et al. 2007 ). Many develop addiction to other substances such as cannabis, cocaine, or methamphetamine ( Grant 2004 ). They also may have other serious psychiatric disorders, such as major depression, serious anxiety disorders, bipolar disorder, or psychosis ( Grant et al. 2004 ; Hasin et al. 2007 ). This is the group who largely populates AA and treatment programs, especially as they age into mid-life ( Moss et al. 2007 ). What is striking is that in almost all treatment programs in the United States, the model for treating such a complicated and chronic illness consists of group counseling and AA, typically for only a few weeks or months ( McLellan and Meyers 2004 ). As noted earlier in this article, this model of treatment was developed when there were no formal treatments for AUDs and when no other methods of treatment were available. Recent findings on severe recurrent AUDs, however, suggest a different approach.

Based on the current understanding of the nature of the disorder, some principles seem relatively straightforward and resemble those for treating other severe chronic disorders. For example, treatment should continue as long as needed and not be stopped at some arbitrary point. The goal of treatment should always be full remission (for this group, this usually is abstinence), but it is not realistic to expect to reach that goal easily or quickly. For some affected individuals, it may not be possible to achieve long-term continuous abstinence at all. In that case, clinicians must be prepared to do everything possible to reduce the severity and impact of the disorder, to extend meaningful life, and to reduce suffering. Familiar examples exist in conditions such as diabetes, bipolar disorder, and cancer. In such cases, the aim is always for a cure, but we do not abandon the patient if cure is not forthcoming. Fortunately, many people with severe recurrent AUDs eventually do get well, which often is not the case with other chronic disorders. In addition to modifying the treatment approach and goals, it is important to attend to coexisting conditions such as psychiatric and physical disorders. Social and vocational functions also are commonly affected and should be addressed as well. Thus, long-term care coordination is essential to providing good care to this group over time.

Providing this level and type of care for severe recurrent AUDs requires new approaches to where services will be provided and by whom. Ideally, physicians (including psychiatrists), other mental health clinicians, nurses, and counselors will coordinate the provision of multiple services, individualized for each patient. Restructuring the continuum of care for at-risk drinking and AUDs is a formidable but not impossible task.

The Future of Treatment Research

The limited scope of this article cannot possibly do justice to the explosive growth in knowledge in neuroscience, genomics, pharmacology, psychology (including behavioral economics), social sciences, and mathematics and the implications for developing new approaches to help people change health behavior. Other articles in this issue summarize some of them. This explosion in knowledge holds great promise for developing new methods for helping people change their health behaviors. Medications aimed at novel targets and more direct behavioral approaches will become available that likely will be significantly more powerful than what are in use now. Research conducted during the past 40 years has enabled us to develop a continuum of care with a solid scientific base, an improvement over the first models of treatment developed decades ago. As the science develops, however, so will the complexity and difficulty of the questions to be answered. Research coupled with a restructured treatment system capable of making new scientific findings rapidly available to the community hold the key to significantly improving treatment outcomes and reducing suffering from alcohol-related disorders.

Behavioral Approaches for Treating Alcohol Dependence.

F inancial D isclosure

The author declares that he has no competing financial interests.

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Helping individuals with firearm injuries: a cluster randomized trial.

Investigators Ali Rowhani-Rahbar, MD, MPH, PhD PI (UW Epidemiology, UW Pediatrics)

Histories of Fatal-Collision Drinking-Drivers: Patterns Among Adults and Youth

Investigators Brent L. Baxter, PhD PI (UW ADAI)

HIV, Drugs, and Sexual Risk in DUMSMs: A Community Study

Hiv, hepatitis, std and reproductive health risk behaviors among female seattle methamphetamine users, hybrid effectiveness-implementation trial of a school-based teen marijuana checkup.

Investigators Denise D. Walker, PhD Multiple PI (UW School of Social Work) Bryan Hartzler, PhD Multiple PI (UW ADAI)

Impacts of Cannabis & Cannabis Legalization on Impaired Driving in WA State

Investigators Caleb Banta-Green, PhD, MPH, MSW PI (UW ADAI) Ali Rowhani-Rahbar, MD, MPH, PhD Co-PI (UW School of Public Health) Beth E. Ebel, MD, MSc, MPH Co-Investigator (UW School of Public Health)

Implementation Survey of PrEP and Opioid Use Related Services in STI Clinics and MSM-Centered Community Based Organizations (CBOs)

Investigators Mary Hatch-Maillette, PhD PI (UW ADAI) Tanja Laschober, PhD Co-Investigator (UW ADAI)

Implementing Contingency Management in a Supportive Housing Context to Promote Resident Well-Being

Investigators Bryan Hartzler Principal Investigator Alanna Feltner Co-investigator Callan Fockele, MD Co-investigator Sarah Leyde, MD Co-investigator

Implementing Contingency Management in Opioid Treatment Centers across New England: A Hybrid Type 3 Trial

Investigators Sara Becker, PhD Multiple PI (Brown) Bryan R. Garner, PhD Multiple PI (RTI International)

Implementing Contingency Management in Oregon-based Health Settings to Address Stimulant Misuse

Investigators John McIlveen, PhD, LMHC PI (Oregon Health Authority) Bryan Hartzler, PhD Sub-award PI (UW ADAI)

Implicit Cognition and HIV Risk Behavior in Drug Users

Improving interactions between law enforcement and people who use alcohol and drugs.

Investigators Mandy Owens, PhD Principal Investigator Jenna van Draanen, PhD Co-Investigator

Increasing Post-Discharge Follow-up Among Hospitalized Smokers

Investigators Kimber P. Richter, PhD, MPH PI (Univ. Kansas) Bia Carlini, PhD, MPH Co-Investigator (UW ADAI)

Informing Dissemination of Behavior Therapies to Enhance HIV Care Among Substance Abusers

Integrating behavioral interventions in substance abuse treatment.

Investigators Bryan Hartzler, PhD Principal Investigator

Integrating Tobacco Cessation Interventions in the Routine of Care of a Rehabilitation Hospital Serving a Rural Population in Washington State

Intervention to increase naloxone engagement and distribution in community pharmacies.

Investigators Anthony S. Floyd, PhD Caleb Banta-Green, PhD, MPH, MSW

Interventions to Improve the HIV PrEP Cascade among Methamphetamine Users

Investigators Joanne D. Stekler, MD, MPH PI (UW Public Health) Caleb Banta-Green, PhD, MPH, MSW Co-Investigator (UW ADAI)

Interviewer Factors in the Elicitation of HIV Risk Networks

Jail medications for opioid use disorder (moud) training and technical assistance, king county opioid treatment access program (kcotap), kitsap outcome evaluation, long-term opioid management of chronic pain: trends and risks.

Investigators Michael Von Korff, ScD PI (Group Health) Caleb Banta-Green, PhD, MPH, MSW Co-Investigator (UW ADAI)

Marijuana Use Among High-Risk Mothers in Washington State

Investigators Therese M. Grant, PhD

Matching Patients to Alcoholism Treatments: Seattle CRU

Investigators Dennis M. Donovan, PhD

Maximizing the Patient-counselor Relationship to Reduce Sexual Risk Behavior [Being Safe in Treatment (BEST)]

Investigators Mary Hatch-Maillette, PhD Mulitiple PI (UW ADAI) Elizabeth Wells, PhD Multiple PI (UW Social Work)

Medical Cannabis in HIV-positive Substance Users

Investigators Howard Newville, PhD PI (UW ADAI)

Medication-First Delivery for High-Acuity Opioid Use Disorder Populations

Meds-first low barrier buprenorphine and behavioral health programs, methadone maintenance in primary care.

Investigators Joseph O. Merrill, MD PI (UW ADAI)

Mindful Awareness in Body-Oriented Therapy for Women’s Substance Abuse Treatment: A Feasibility Study

Investigators Cynthia Price, PhD PI (UW School of Nursing) Dennis M. Donovan, PhD

Model State-Supported Area Health Education Center Program

Investigators John McCarthy, MD Principal Investigator Bryan Hartzler, PhD Subcontract Principal Investigator Denna Vandersloot, MEd Subcontract Principal Investigator

Modeling Individual Heterogeneity in the Alcohol Relapse Process

Motivational enhancement to reduce risk of street youth, multi-state examination of cannabis use disorder rates in hiv care, native center for alcohol research and education (ncare).

Investigators Dedra Buchwald, MD PI (WSU) Dennis M. Donovan, PhD Co-Investigator (UW ADAI)

Native Healing and Wellness Conference

Investigators Lisa Rey Thomas, PhD PI, UW ADAI

Native Pathways to Sobriety: Pacific Northwest Oral Life Histories

Investigators Lisa Rey Thomas, PhD PI (UW ADAI)

Navigating Our Strengths and Needs: A Community Assessment Project for the Jamestown S’Klallam Tribe

Investigators Sandra M. Radin, PhD

Neuronal Mediation of Ethanol-Induced Taste Aversions

Investigators Todd E. Thiele, PhD PI (UW ADAI)

NIDA Clinical Trials Network (CTN), Pacific Northwest Node

Investigators Mary Hatch-Maillette, PhD Co-PI (UW ADAI) John Roll, PhD Co-PI (WSU)

NIDA CTN-0015: Women’s Treatment for Trauma and Substance Use Disorders

Investigators Denise Hien, PhD Lead Investigator (Saint Luke's Roosevelt Hospital Center"

NIDA CTN-0018: Reducing HIV/STD Risk Behaviors: A Research Study for Men in Drug Abuse Treatment

Investigators Donald A. Calsyn, PhD Lead Investigator (UW ADAI)

NIDA CTN-0019: Reducing HIV/STD Risk Behaviors: A Research Study for Women in Drug Abuse Treatment

Investigators Susan Tross, PhD Lead Investigator (NY State Psychiatric Inst.)

NIDA CTN-0027: Starting Treatment with Agonist Replacement Therapies (START)

Investigators Walter Ling, PhD Lead Investigator (UCLA)

NIDA CTN-0030: Prescription Opiate Abuse Treatment Study (POATS)

Investigators Roger Weiss, MD Co-Lead Investigator (Harvard Medical School) Walter Ling, MD Co-Lead Investigator (UCLA)

NIDA CTN-0031: Stimulant Abuser Groups to Engage in 12-Step (STAGE-12): Evaluation of a Combined Individual-Group Intervention to Reduce Stimulant and Other Drug Use by Increasing 12-Step Involvement

Investigators Dennis M. Donovan, PhD Co-Lead Investigator (UW ADAI) Dennis Daley, PhD Co-Lead Investigator (Western Psychiatric Institute and Clinic)

NIDA CTN-0044: Web-Delivery of Evidence-Based, Psychosocial Treatment for Substance Use Disorders

Investigators Edward V. Nunes, MD Lead Investigator (Columbia University)

NIDA CTN-0047: Screening Motivational Assessment and Referral to Treatment in Emergency Departments (SMART-ED): Evaluation of Screening, Brief Intervention, Referral to Treatment (SBIRT) and Booster Session for Drug Use Patients Presenting for Treatment in the Emergency Department

Investigators Michael Bogenschutz, MD Co-Lead Investigator (UNM CASAA) Dennis M. Donovan, PhD Co-Lead Investigator (UW ADAI)

NIDA CTN-0048: Cocaine Use Reduction with Buprenorphine (CURB)

Investigators Walter Ling, MD Lead Investigator (UCLA) Andrew Saxon, MD Co-Lead Investigator (VA Puget Sound) Larissa Mooney, MD Co-Lead Investigator (UCLA)

NIDA CTN-0050: Long-Term Follow-Up of START Patients

Investigators Yih-Ing Hser, PhD Co-Lead Investigator (UCLA) Walter Ling, MD Co-Lead Investigator (UCLA)

NIDA CTN-0051: Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT)

Investigators John Rotrosen, MD Lead Investigator (NYU)

NIDA CTN-0069: Opioid Use Disorder in the Emergency Department (Project ED Health)

Investigators Gail D'Onofrio, MD, MS PI (Yale University) David Fiellin, MD Co-Investigator (Yale University)

NIDA CTN-0078: Knowledge of and Attitudes about Medication Assisted Treatment within American Indian Communities

Investigators Sandra M. Radin PI (UW ADAI) Dennis M. Donovan, PhD Co-Investigator (UW ADAI) Dennis Wendt, PhD Co-Investigator (McGill)

NIDA CTN-0080: Medication Treatment for Opioid Use Disorder in Expectant Mothers (MOMs): A Pragmatic Randomized Trial Comparing Two Buprenorphine Formulations

Investigators T. John Winhusen, PhD Lead Investigator (University of Cincinnati)

NIDA CTN-0082: Implementation Survey of PrEP and Opioid Use Related Services in STI Clinics and MSM-Centered Community Based Organizations (CBOs)

Investigators Susan Tross, PhD, Columbia University Mary Hatch, PhD, UW Addictions, Drug & Alcohol Institute

NIDA CTN-0096: Culturally Centering Medications for Opioid Use Disorder with American Indian and Alaska Native Communities

Nida ctn-0099: emergency department-initiated buprenorphine and validation network trial (ed-innovation), nida ctn-0131: office-based methadone versus buprenorphine to address retention in medication for opioid use disorder (moud)– a pragmatic hybrid effectiveness/implementation trial.

Investigators David Fiellin, MD Lead Investigator (Yale University)

Northwest Addiction Technology Transfer Center

Investigators Bryan Hartzler, PhD Co-Director (UW ADAI) Denna Vandersloot, MEd Co-Director

NW High Intensity Drug Trafficking Area Drug Court Evaluation

Investigators Gary B. Cox, PhD

Olympia Bupe Clinic Evaluation

Opioid response network/str-ta.

Investigators Bryan Hartzler, PhD (UW ADAI/Northwest ATTC) Denna Vandersloot, MEd

Opioid State Targeted Response – Technical Assistance For HHS Region 10

Investigators Kathryn Cates-Wessel Principal Investigator Bryan Hartzler, PhD Subcontract Principal Investigator Denna Vandersloot, MEd Subcontract Principal Investigator

Oregon State Opioid Response

Investigators John W. McIlveen, Ph.D., LMHC Principal Investigator Bryan Hartzler, PhD Subaward Principal Investigator

Outcome Analyses of Persons in Chemical Dependency Treatment

Parent-child assistance program: intervention with high-risk alcohol and drug abusing mothers.

Investigators Susan A. Stoner, PhD PI (UW ADAI)

Peer Engagement in Methamphetamine Harm Reduction with Contingency Management

Investigators Todd Korthuis, MD, MPH PI (OHSU) Bryan Hartzler, PhD Co-Investigator (UW ADAI)

Pierce County Opiate Epidemiology and Treatment Needs

Pioneer center north evaluation, prescription drug overdose prevention for states, prescription opioid misuse in a large hmo.

Investigators Caleb Banta-Green, PhD, MPH, MSW PI (UW ADAI) Donald Calsyn, PhD Original PI (UW ADAI)

Preventing Addiction Related Suicide

Investigators Richard K. Ries, MD PI (UW Psychiatry) Dennis M. Donovan, PhD Co-Investigator (UW ADAI)

Promoting Healthy Families and Relationships: Exploring Domestic Violence and Tribal Community Culture to Inform Best Practices

Investigators Sandra M. Radin, PhD PI (UW ADAI) Teresa C. Evans-Campbell, PhD Co-Investigator (UW School of Social Work)

Promoting Healthy Families for High Risk Mothers and Babies in PCAP

Investigators Nancy Grote, PhD PI (UW School of Social Work) Therese M. Grant, PhD Consultant (UW ADAI)

Promoting Healthy Families: A Mental Health Treatment and Intensive Case Management Task-Sharing Approach

Investigators Susan A. Stoner, PhD UW ADAI Amritha Bhat, MBBS, MD, MPH UW Psychiatry & Behavioral Sciences

Psychology Training in Alcohol Research

Investigators Mary E. Larimer, PhD PI (UW) Dennis M. Donovan, PhD Primary Faculty Member, Mentor (UW ADAI)

Quantitative Drug Surveillance System Development

Investigators Caleb Banta-Green, PhD, MPH, MSW PI (UW ADAI) Jennifer A. Field, PhD Co-Investigator (Oregon State University)

Racial Inequalities in Health Throughout Adulthood: The Cumulative Impact of Neighborhood Chemical and Non-Chemical Stressors on Epigenomic Pathways

Re-engagement in evidence-based quitline treatment for low income smokers, recovery café evaluation.

Investigators Mandy Owens, PhD Principal Investigator Caleb Banta-Green, PhD, MPH, MSW Principal Investigator

Risk-Taking Behaviors and Cryptocurrency Trading (REACT) in Young Adults

Investigators Caislin Firth, PhD, MPH

Role of Neuropeptide Y in Ethanol Consumption

Sbirt learning collaborative for mental illness and drug dependency plan-funded emergency department providers.

Investigators Bryan Hartzler Contract PI Denna Vandersloot Contract PI

Smokefree Hospitals Initiative

Investigators Abigail Halperin, MD, MPH PI (UW Family Medicine) Bia Carlini, PhD, MPH Co-Investigator (UW ADAI)

Snohomish County Drug Court Implementation Grant Evaluation

Ssi battelle, ssi project evaluation, state opioid response technical assistance, state opioid response/tribal opioid response technical assistance.

Investigators Kathryn Cates-Wessel PI (AAAP) Bryan Hartzler, PhD Subcontact PI (UW ADAI)

Substance Abuse Prevention in the Elderly: Review of the Literature

Investigators Katherine A. Carlson, PhD

Substance Use and HIV Clinic Care

Substance use and hiv risk, substance use and predictors of risk behavior, substance use and suicide in street youth.

Investigators Joshua Ginzler, PhD

Tailoring “Real Men Are Safe” for African American and Hispanic Men

Investigators Donald A. Calsyn, PhD PI (UW ADAI)

Technology-Enhanced Quitline Services to Prevent Smoking Relapse

Investigators Anna M. McDaniel, PhD, RN, FAAN PI (Univ. Indianapolis) Bia Carlini, PhD, MPH Co-Investigator (UW ADAI) Katie Witkiewitz, PhD Co-Investigator (UW ADAI)

The Healing of the Canoe

Investigators Dennis M. Donovan PI (UW ADAI) Lisa Rey Thomas, PhD Co-Investigator (UW ADAI)

Toolkit for Enhancing Client Retention in Substance Abuse Treatment

Investigators Sandra M. Radin, PhD PI (UW ADAI)

Toxicology Lab Data Epidemiology

Training and intensive technical assistance in motivational interviewing.

Investigators Bryan Hartzler, PhD Principal Investigator Denna Vandersloot, MEd Principal Investigator

Training and Intensive Technical Assistance in Motivational Interviewing for Behavioral Health and Medical Providers

Training and technical assistance for behavioral health providers in washington state, training for behavioral health providers addressing people with substance use disorders in washington state, training primary care professionals in motivational interviewing, training-of-trainers process for screening, brief intervention, and referral to treatment, training, technical assistance, and leadership services to support workforce development initiatives, transcriptional, functional, and circuit profiling at single cell resolution of neuronal ensembles engaged by heroin relapse.

Investigators Susan M. Ferguson, PhD Garret Stuber, PhD

Treatment of At-Risk Drinkers in Primary Care

Treatment outcomes of dasa clients, university of washington center of excellence in opioid addiction research, using data to drive action to reduce opioid overdoses in seattle, wa.

Investigators Caleb Banta-Green, PhD, MPH, MSW Principle Investigator (UW ADAI) Julia Hood, PhD Co-Investigator (Public Health — Seattle & King County)

Using Narratives to Identify Stigma Phenotypes – A Socio-Ecological Approach

Investigators Beatriz Carlini Beatriz Carlini, PhD, MPH

Using Policy Codesign to Achieve Multi-Sector Alignment in Adolescent Behavioral Health

Investigators Sarah Cusworth Walker, PhD PI

Using the Internet to Recruit Immigrants with Limited English Proficiency for Tobacco Use and Alcohol-Related Disorders Screening: A Pilot Study Among Brazilian Immigrants

Wa state community drug checking network (cdcn).

Investigators Caleb Banta-Green

WA State Syringe Service Program Health Survey

Wa-str addresses the opiate epidemic by increasing treatment and prevention activities, washington state innovation initiative: medication assisted treatment upon release from prison.

Investigators Caleb Banta-Green, PhD, MSW, MPH PI (UW ADAI)

Washington State Opioid Response (SOR) Grant

Washington state project to prevent prescription drug/opioid overdose (wa-pdo).

Investigators Caleb Banta-Green, PhD, MPH, MSW PI of Subaward from DBHR (UW ADAI)

Washington Tribes and RAIO Health Priorities Summit

Wastewater-based epidemiology of drug use, web-assisted tobacco intervention with community college students.

Investigators Scott McIntosh, PhD PI (Univ. of Rochester) Bia Carlini, PhD, MPH Co-Investigator (UW ADAI)

Web-Based Skills Training: SBIRT-PC

Investigators Susan A. Stoner, PhD PI (Talaria, Inc./UW ADAI) Bia Carlini, PhD, MPH Co-Investigator (UW ADAI) Kelly M. Carpenter, PhD Co-PI

Welcome Back: Evaluating Strategies to Re-Engage Smokers in Quitline Cessation Services

Women’s hiv risk: alcohol intoxication, victimization history, & partner factors, youth and young adult sud and cod trainings.

Investigators Bryan Hartzler Principal Investigator

Youth Clinician Training

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A research proposal on drug as social problem

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Nader Ghotbi

The dramatic increase of poppy cultivation and opium production in Afghanistan has led to a serious drug addiction problem in te world. The rising heroin use, because of needle sharing, may lead to a much higher incidence of HIV infection and AIDS in Afghanistan in the future. We organized two expeditions into Afghanistan itself, one through the capital, Kabul and

Aims To provide an overall picture of drug abuse in Vietnam, its prevalence, correlates and patterns. Methods Studies addressing the drug abuse problem in Vietnam are reviewed. Attention is paid to studies conducted from 1993 onwards. The reviewed studies were collected from both refereed and non-refereed sources. Results Drug abuse is rising sharply in Vietnam: almost threefold over the past 10 years. From a predominantly rural-mountainous phenomenon, illicit drug abuse spread rapidly to urban areas. Meanwhile, the average age of drug users has declined and more women have been engaging in drug consumption. At the same time, heroin has replaced opium as the most preferred drug in the country's illicit drug market, especially among young users in urban areas. At the national level, the second main route of drug administration, injecting, has exceeded smoking and taken precedence in the country's drug abuse culture, especially among heroin users. Conclusion Drug abuse in Vietnam has changed radically over the past decade, which has implications for the national and international community and requires further research to fill the knowledge gap and to inform intervention policy for better drug control policy.

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Abbas Badakhshan

Objectives: This study was conducted to estimate the prevalence and the associated factors of high-risk sexual behaviors among drug abusers referred to a methadone clinic in Gorgan, the capital of Golestan province in the northeast of Iran, to help health care decision makers on designing interventional programs. Methods: In this cross-sectional study, 400 drug abusers referred to our methadone clinic were evaluated for high-risk sexual behavior. A logistic regression model was fitted for the association between independent variables ...

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ANEELA SHEIKH

The objective of this paper is to highlight the drug menace among women and to analyze the factors responsible for drug usage by the women. The personal profiles of the women, frequency and sources of drug provision were analyzed towards the greater knowledge of the concerning issue. This may facilitate the policy-makers to devise more efficient means of averting drugs usage. Accidental and snow ball sampling techniques were employed for data collection. The sample comprised 250 women, aged ≥ 18 years, selected from the population were interviewed for psychotropic drug abuse (for insomnia, nervousness, tiredness, headache and anxiety) and socio-demographic attributes comprising income, employment, profession and habits. It was found that the most contributing factors towards drug addiction were psychological, followed by social and economic factors respectively. The increased tendency of women seeking solace in drugs calls for immediate policy interventions and strict monitoring for...

Festus U W A K H E M E N Asikhia

The issue of drugs and substance abuse by the youth is on the increase, and it has called for social concern. Despite the fact and growing appreciation of the need for drugs and substance abuse control, it would appear there is a lack of enough empirical research in Nigeria which explicitly links drugs and substance abuse to youth development. This study, therefore, examines the relationship between drugs, substance abuse and effects on youth development in Nigeria with specific reference to Lagos state. The study adopted the cross-sectional survey design and data is generated through a self-administered questionnaire. Data for the analysis was generated from a total of 344 participants selected from official, detainees and prisoners from eight directorates in the National Drug Law Enforcement Agency (NDLEA), and the Nigerian Prisons Service (NPS)in Lagos State. The analysis centred on investigating the impact of the drug, substance abuse on the four identified measures of youth development, namely: crime, academic performance, impaired memory, mental health problems and contracting infectious disease (HIV and STDs). The univariate analysis revealed that on average, almost all the respondents affirmed the significant manifestations of the variables within the data generated. For the bivariate hypotheses, Spearman's rank-order correlation was utilized in testing the extent of correlations between drug, substance abuse and effects on youth development. The results revealed that there is a relationship between drug, substance abuse, and crime at a 0.05 level of significance, it also revealed that there is a relationship between drug substance abuse and academic performance at a 0.05 level of significance, the third hypotheses of the study revealed that there is a relationship between drug, substance abuse, and impaired memory and mental health problem at a 0.05 level of significance, it also revealed that there is a relationship between drug, substance abuse and contracting infectious diseases at a0.05 level of significance. As such, all four (4) null hypotheses of no significant relationships were rejected. In conclusion, this study asserts that drug, substance abuse, is significantly associated and enhances manifestations of youth development and as such enhances outcomes such as crime, academic performance, impaired memory, mental health problems, and contracting infectious diseases. It, therefore, recommends that, for an improved standard of living, and improved facility for a reintegration of drug abusers, tight border control, strengthening of drug agencies and strong policies against drugs and substance abuse and finally awareness creation, sensitization on drug use and viable youth development programs

Sanaz Helmi

ED/ INDEXED IN: COPERNICUS, INDEX COPERNICUS IRAN, Directory Of Research Journal Indexing (DRJI), J-Gate, EBSCO, SCIRUS, Eyesourse,Electronic Journals Library (EZB), SSRN eLibrary, Global Impact Factor (GIF), Google Scholar, Research Bible, NewJour, Magiran, Sjournals, Iran Journal. The Role of Impulsivity, Risk-Taking, and Sensation-Seeking in People Prone to Substance Abuse 49 The Role of Impulsivity, Risk-Taking, and Sensation-Seeking in People Prone to Substance Abuse

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