Loosening the Grip: a handbook of Alcohol Information 9th

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Caplan AL. Ethical issues surrounding forced, mandated, or coerced treatment. Journal of Substance Abuse Treatment 31(2): 117–120, 2006. (7 refs.)

This is a special article on the ethics of complusory treatment. In brief, when someone argues in favor of mandatory treatment of drug-addicted individuals on the grounds that they will greatly benefit from a new drug or vaccine or that society will greatly benefit, these arguments are viewed as working up a very steep ethical hill. Regardless of the benefit, the notion of overriding a person's autonomy and forcing any type of treatment upon him or her is going to fall on the value of autonomy. A person has the fundamental right, well established in medical ethics and in American law, to refuse beneficial and helpful care even if such a refusal shortens his or her own life and has detrimental consequences for others. Although many proponents of mandatory treatments for drug-addicted prisoners are inclined to point to the benefits both for prisoners and for society, it is exceedingly unlikely that any form of treatment that is forced, coerced, or mandated upon a vulnerable population such as prisoners is going to find any traction in American ethics, law, or public policy. There is, however, a way in which self-determination may not conflict so strongly with the compulsory use of drugs for prisoners. The argument that is being made is that respect for self-determination sometimes requires mandatory treatment as a way to create or enable autonomy. It is not plausible to infringe on autonomy or force treatment in the name of public health or patient benefit when we rarely do so in other contexts. Nor are such arguments oriented toward the best interest of the person being forced to take treatment. However, if, for example, the research on naltrexone is sound, if it is possible to say that treatment can enhance, restore, build up, and add to the autonomy that drug-addicted individuals have by letting them be free from cravings, drives, and habits that inhibit their capacity to make choices, then doctors and prison officials can mandate treatment in the short run. The moral basis for this intervention is for the good of the patient and their autonomy. How long and whether someone ought to be able at some point say, “I've done this for six months, I'm finished, I want to get high again” are problems. But that is not the problem that has to be addressed first. The moral challenge is to open the door to mandatory treatment. Moreover, this argument can be put to an empirical test. If, at the end of a mandatory treatment period, prisoners or former prisoners feel that their autonomy and their self-determination are increased and enhanced following a run of naltrexone, then this justifies temporarily ignoring their autonomy. It may press current ethical thinking to the limit, but mandating treatment in the name of autonomy is not as immoral as many might otherwise deem forced treatment to be. Copyright 2006, Elsevier Science

Day A, Tucker K, Howells K. Coerced offender rehabilitation—A defensible practice? Psychology, Crime & Law 10(3, special issue): 259–269, 2004, 2005. (38 refs.)

The use of the criminal justice system to force offenders to receive psychological treatment is one of the most controversial aspects of service provision for offenders. Coerced treatment needs to be distinguished from pressured treatment, both having objective and subjective dimensions. In this paper some arguments for and against coerced offender rehabilitation are discussed. We suggest that coercing offenders into attending rehabilitation programmes (or placing legal pressure on them to attend) is unlikely by itself to lead to poorer outcomes. Rather, the individual's perception of coercion will be more influential in determining how an offender approaches treatment. Even when offenders perceive they are being coerced, it is likely that pretreatment anti-therapeutic attitudes can change over the course of a programme, such that therapeutic gains (risk reduction) can occur. Coercion and its effects on treatment engagement and rehabilitation outcomes require further empirical research and conceptual analysis. Copyright 2004, Routledge, Taylor & Francis Ltd.

Doyle K. Substance abuse counselors in recovery: Implications for the ethical issue of dual relationships. Journal of Counseling and Development 75(6): 428–432, 1997. (16 refs.)

The issue of dual relationships is a significant ethical challenge for all counselors. For the counselor recovering from an addiction to substances, this issue can be even more problematic. Existing codes of ethics offer insufficient guidance to the recovering counselor. Following an overview of dual relationships, the author reviews the ethical codes of the American Counseling Association and the National Association of Alcoholism and Drug Abuse Counselors, with particular attention paid to their applicability to the recovering counselor. Potentially difficult situations are considered, and recommendations are offered both for the recovering counselor and for the counseling field in general to minimize the incidence of unethical behavior due to dual relationship issues. Copyright 1997, American Association for Counseling and Development

Gruning T, Gilmore AB, McKee M. Tobacco industry influence on science and scientists in Germany. European Journal of Public Health 15(Supplement 1): 51, 2006

Background: Germany is noted within Europe for its remarkable reluctance to implement effective tobacco control policies. Using internal tobacco industry documents we examined how and why the tobacco industry sought to induce the German scientific community and its research as a possible factor in explaining the opposition to stricter tobacco regulation in Germany. In so doing we contribute to the debate about the scientific and ethical acceptability of performing and publishing tobacco industry-funded research. Methods: Industry documents in German and English languages released through litigation in the USA were identified through online searches of tobacco document websites. In total, over 2238 documents were retrieved and analyzed to construct a historical and thematic narrative. Results: Smoking and health research programmes were organized both separately by individual tobacco companies and jointly through their trade organization. An extensive network of individual scientists and scientific institutions with tobacco industry links was developed. many leading scientists collaborated with the industry, in some case very closely. Science was heavily influenced by the tobacco industry. To explain the systems of influence we developed a model which distinguishes five ways of distorting science: suppression, dilution distraction, concealment, and manipulation. Concussion: The extent of industry influence over the scientific and medical establishment in Germany is profound and the industry introduced serious bias into the research outputs likely to have influenced scientific consensus and public opinion in Germany. This can be expected to have increased the social acceptability of smoking, influenced the policy context, and undermined efforts to control tobacco use. Tobacco industry influence on German science and scientists may help to explain the opposition to effective tobacco regulation in Germany. Copyright 2005, Oxford University Press

Hall W. The role of legal coercion in the treatment of offenders with alcohol and heroin problems. Australian and New Zealand Journal of Criminology 30(2): 103–120, 1997. (71 refs.)

This article discusses the ethical justification for and reviews the American evidence on the effectiveness of treatment for alcohol and heroin dependence that is provided under legal coercion to offenders whose alcohol and drug dependence has contributed to the commission of the offence with which they have been charged or convicted. The article focuses on legally coerced treatment for drink-driving offenders and heroin-dependent property offenders. it outlines the various arguments that have been made for providing such treatment under legal coercion, namely, the over-representation of alcohol and drug dependent persons in prison populations; the contributory causal role of alcohol and other drug problems in the offences that lead to their imprisonment; the high rates of relapse to drug use and criminal involvement after incarceration; the desirability of keeping injecting heroin users out of prisons as a way of reducing the transmission of infectious diseases such as HIV and hepatitis; and the putatively greater cost-effectiveness of treatment compared with incarceration. The ethical objections to legally coerced drug treatment are briefly discussed before the evidence on the effectiveness of legally coerced treatment for alcohol and other drug dependence is reviewed. The evidence, which is primarily from the USA, gives qualified support for some forms of legally coerced drug treatment provided that these programs are well resourced, carefully implemented, and their performance is monitored to ensure that they provide a humane and effective alternative to imprisonment. Expectations about what these programs can achieve also need to be realistic. Copyright 1997, The Australian & New Zealand Society of Criminology

Hannum H. The Dublin Principles of Cooperation among the beverage alcohol industry, governments, scientific researchers, and the public health community (editorial). Alcohol and Alcoholism 32(6): 639–640, 1997.

This is a reprinting of the Principles, known as the 'Dublin Principles', adopted as a consensus statement and suggested for adoption by the alcohol industry, governmental groups, and researchers. It addresses the mutual responsibility of the beverage industry and researchers to comport themselves in an ethical fashion, to avoid conflict of interests or the appearance; the obligation in situations of providing educational information to do so in an unbiased fashion; that alcohol policies should reflect a combination of government regulation, industry self-regulation and individual responsibility. Only legal responsible consumption of alcohol should be promoted by the beverage alcohol industry.

Kleinig J, ed. Special issue on ethical issues of substance intervention. Substance Use & Misuse 39(3): entire issue, 2004. (article refs)

This issue considers the ethical questions raised by governmental and medical interventions into drug use. With respect to the former, it begins with the liberal assumption that constraints on free action are to be justified by reference to its deleterious impact on others, but then qualifies that assumption by noting the social requisites of free action. With respect to medical interventions, it focuses on the codes that have been developed for treatment providers and their clients, and explores the ethical underpinnings of several of their central provisions -- informed consent, privacy, confidentiality, nondiscrimination, professionalism, and accountability. Articles address harm reduction, syringe disposal, , Copyright 2004, Project Cork

Pratt WM, Davidson D. Does participation in an alcohol administration study increase risk for excessive drinking? Alcohol 37(3): 135–141, 2005. (18 refs.)

It has long been thought that research protocols involving alcohol administration may exacerbate problem drinking in alcoholic subjects following their participation in such a study. However, recent studies suggest that involvement in an alcohol administration study does not, in fact, have a negative impact on subsequent drinking behavior. In the present study, 27 non-treatment-seeking alcohol-dependent subjects and 32 social drinkers participated in an alcohol administration study designed to investigate the effects of repeated doses of alcohol on craving, mood, and alcohol-seeking behavior. The volume of alcohol administered to the subjects was calculated in such a way that their blood alcohol concentration would reach a peak of 0.08 g/dl midway through testing. Before their release, alcohol-dependent subjects were given feedback regarding their level of alcohol consumption and provided with information about the potential harmful effects of their drinking behavior. Percentage of days abstinent (PDA), drinks per drinking day (D/DD), and percentage of heavy drinking days (PHDD, defined as >= 4 drinks per occasion for females and >= 5 drinks per occasion for males) were recorded for the 6 weeks preceding laboratory testing and for the 6 weeks following participation in the study. The alcohol-dependent subjects exhibited a significant increase of 24% in PDA during the poststudy period compared to the prestudy period. They also decreased their D/DD by 2.4 drinks per occasion, and decreased their PHDD by 21.6%. There were no differences in PDA or D/DD for the social drinkers between pre- and poststudy periods. There was, however, a small but significant increase of 3.5% in PHDD for the social drinkers following laboratory testing. These data suggest that participation in an alcohol administration study does not put alcoholic subjects at risk for increased alcohol consumption following study participation. In fact, participation in such studies may actually precipitate at least a temporary decrease in alcohol consumption, especially when paired with a brief intervention session. Thus, non-treatment-seeking alcoholics can be safely included in alcohol administration studies to provide results that are most relevant to the population of interest. Copyright 2005, Elsevier Science Ltd.

Rhule DM. Take care to do no harm: Harmful Interventions for youth problem behavior. Professional Psychology: Research and Practice 36(3): 618–625, 2006. (45 refs.)

Youth conduct problems, delinquency, and substance abuse pose serious consequences for the youth themselves, their victims and families, and the broader society. The widespread impact of these problem behaviors highlights the importance of preventing and treating them effectively. Despite this need, an emerging literature has demonstrated that certain intervention programs for these problem behaviors, particularly those that have used group-delivery formats, have produced iatrogenic effects. The potential for intervention to produce negative outcomes raises several ethical implications and dilemmas. In this article, the author provides illustrative examples of iatrogenic effects of interventions that target youth conduct problems, delinquency, and substance abuse; discusses the relevant ethical implications raised by these outcomes; and suggests recommendations to prevent, detect, and respond to their occurrence. Copyright 2005, American Psychological Association

Scott CG. Ethical issues in addiction counseling. Rehabilitation Counseling Bulletin 43(4): 209–214, 2000. (31 refs.)

Although all counselors face ethical challenges, addictions counselors encounter ethical issues that are, in many respects, unique to their discipline. This article provides an overview of these issues, which include but are not limited to (a) the lack of communication and continuity between research and clinical practice, (b) lack of agreement over the necessary professional credentials, (c) the questionable propensity of group work in the addictions field, (d) special issues of confidentiality and privileged communication, (e) boundaries of professional practice in making treatment decisions, and (f) unusual circumstances of informed consent. In addressing these issues, addictions counselors must not only uphold the ethical standards of their profession, they must also be cognizant of any federal statutes that may supersede their state regulations and act in accordance with them. Copyright 2000, American Rehabilitation Counseling Association

Walker R, Logan TK, Clark JJ, Leukefeld C. Informed consent to undergo treatment for substance abuse: A recommended approach. Journal of Substance Abuse Treatment 29(4): 241–251, 2005. (67 refs.)

With more than 3 million persons receiving substance abuse treatment per year in the United States and with increasing interest in treatment outcomes, there is a need for closer attention to all aspects of the treatment process. However, minimal attention has been given to informed consent as a way of enlisting client engagement and active participation in treatment. Although there is some literature on informed consent in substance abuse research, the literature on informed consent to undergo substance abuse treatment is very limited. Incorporating informed consent into substance abuse treatment is recommended as part of motivational interviewing. Standard treatment consent issues include (1) the clinical characteristics of the problem, including diagnosis; (2) treatment recommendations; (3) the risks and benefits of treatment; (4) the financial costs of the intervention; (5) alternative services or interventions should a client refuse the recommended form of care; and (6) freedom to choose or refuse treatment. This article provides a background for informed consent procedures to facilitate client engagement in substance abuse treatment and suggests needs for future research on informed consent to undergo substance abuse treatment. Copyright 2004, Elsevier Science

Warner EA, Walker RM, Friedmann PD. Should informed consent be required for laboratory testing for drugs of abuse in medical settings? (review). American Journal of Medicine 1115(1): 54–58, 2003. (30 refs.)

Laboratory testing for drugs of abuse is often conducted in medical settings, with little consideration of the technical limitations and the potential for legal and social harm to the patient. We consider several technical problems associated with such testing, including the lack of chain-of-custody procedures, the possibility of false-positive results with screening immunoassays, and the infrequency of confirmatory testing. Important ethical issues arise because of the sensitive nature of drug test results, the ramifications of false-positive results, the limitations of confidentiality protection, and the practice of testing without the patient's knowledge. Taken together, these technical and ethical concerns suggest that drug testing policies in medical settings should specify which conditions require explicit informed consent, as well as create procedures for protecting this sensitive information. Copyright 2003, Exerpta Medica, Inc.

Weinstein BA, Raber MJ. Ethical assessment of structured intervention with chemically dependent clients. Employee Assistance Quarterly 13(3): 19–31, 1998. (22 refs.)

Structured intervention is a widely accepted approach to helping the chemically dependent client get treatment. Because this method departs from the tradition of the client directly seeking help, it raises unique ethical dilemmas, for both client and practitioner, including issues of self-determination, secrecy, coercion, environmental manipulation, and "fair exchange." Analysis of these issues using a model for ethical decision-making is followed by discussion of four ethical options for the practitioner. The authors identify a preferred ethical position based on theoretical and practice knowledge plus professional and personal values. Copyright 1997, Haworth Press, Inc.


Anderson P, Baumberg B. Alcohol in Europe: A Public Health Perspective. London: Institute of Alcohol Studies, 2006. (Chapter refs)

This report commissioned by the European Commission addresses the social, health, and economic burden associated with alcohol use in Europe. The European Union is the heaviest drinking region of the world, although the current 11 litres of pure ethanol consumed annually is substantially less the 15 litres of the mid-1970s. Alcohol is estimated to generate social costs related to health, welfare, employment and criminal justice system, costs estimated to be 125 billion Euros per year. In addition it promotes social inequalities throughout the European Union with a negative impact on social cohesion. While must has been done to reduce this, the report identifies areas in which further efforts are warranted. The report is organized into 10 chapters. Chapter 1 provides an introduction and outlines the methods used and key terminology and the structure of the report. Chapter 2 provides a brief history of alcohol use in Europe. Chapter 3 describes the economic impact of alcohol, with attention to global and European production and trade. It also considers smuggling and lost taxes, annual expenditures, and social costs. Chapter 4 deals with drinking patterns in Europe, drinking context, estimates of drinking frequency, and differences in drinking patterns related to gender and social class. Chapter 5 describes the impact of alcohol use on individuals - on social well-being, health status, injury and disease rates - while also considering determinants of risk factors. Chapter 6 will address health from the societal perspective, summarizing the numbers of those with different alcohol-related conditions, as well as societal parameters of harm, i.e. crime, violence, and impact on the family. The relationship of harm to population levels of consumption is reviews. Chapter 7 deals with alcohol policy, namely what does and does not work. Detailed attention is directed to drinking and driving, policies that support education, promote harm reduction, and promote advice and treatment. Chapter 8 deals with global and European factors that impinge of alcohol policy, with attention to General Agreement of Tariffs and Trade (GATT), tax policy, monopolies and advertising. Chapter 9 summarizes current alcohol policy in Member Sates, and compares countries over time and in relation to other geographical areas. Chapter 10 summarizes major points and makes recommendations of actions to promote the health of citizens. The recommendations fall into nine areas, ranging from drinking and driving to reducing harm in drinking establishments, to tax measures advertising. Data is summarized in multiple tables and charts.

Babor T, Caetano P, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: No Ordinary Commodity. Oxford: Oxford University Press, 2003. (chapter refs)

This volume, with 16 chapters and 15 contributors, was sponsored by the World Health Organization. In preparing the report, the goal was to create a document that could inform public policy. This volume is the third in a series that has endeavored to provide information relevant to addressing what is a major contributor to morbidity and mortality worldwide. The report is organized into four sections. Following an introduction, Section II is directed to describing why alcohol is no ordinary commodity. It sets forth data on the trends and patterns of alcohol consumption, and then provides epidemiological data on the global burden of alcohol-related problems. The third part of the book is titled "The Toolkit: Strategies and Interventions." This section reviews the scientific evidence for differing approaches designed to prevent or minimize alcohol-related harm. These include pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drinking-driving countermeasures, the regulation of alcohol promotion, education and persuasion strategies, and also early intervention and treatment services. The fourth section considers policymaking, the ingredients for effect policy at both the national and international levels, and also provides a synthesis of evidence-based strategies and interventions from a policy perspective. copyright 2003, Project Cork

Beck J. 100 years of “just say no” versus “just say know”: Reevaluating drug education goals for the coming century (review). Evaluation Review 22(1): 15–45, 1998. (112 refs.)

This historical overview examines school-based drug education programs in the United States from the late 1800s to the present. Particular attention is paid to the influential "scientific temperance instruction" developed by the Woman's Christian Temperance Union (WCTU) as the beginnings of the dominant no-substance-use injunction in drug education. Opposition to this approach and its use of scare tactics has only come from those viewing informational efforts as advertising "forbidden fruits," leading to the alternative of "Just Say Nothing." Although alcohol and tobacco were the primary targets of early "Just Say No" prevention campaigns, they have more recently been replaced by drugs such as heroin, cocaine, and marijuana. While advocacy of informed choice or harm reduction ("Just Say Know") approaches has been present in the past, notably during the Prohibition Era and the 1970s, evaluation of prevention programs continues to be constrained by the no-use dictate and leaves critical educational effectiveness indices unexamined. A pragmatic alternative to the "Just Say No" goal of drug education is offered that focuses on minimizing harm from uninformed misuse of both licit and illicit drugs. A strategy for evaluating the effectiveness of informed choice and harm reduction drug education is discussed. Copyright 1998, Sage Publications, Inc.

Brown JH. Youth, drugs and resilience education (review). Journal of Drug Education 31(1): 83–122, 2001. (168 refs.)

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