Potentially harmful substance use is common, but many affected people do not receive treatment. Brief face-to-face treatments show impact, as do strategies to assist self-help remotely, by using bibliotherapies, computers or mobile phones. Remotely delivered treatments offer more sustained and multifaceted support than brief interventions, and they show a substantial cost advantage as users increase in number. They may also build skills, confidence and treatment fidelity in providers who use them in sessions. Engagement and retention remain challenges, but electronic treatments show promise in engaging younger populations. Recruitment may be assisted by integration with community campaigns or brief opportunistic interventions. However, routine use of assisted self-help by standard services faces significant challenges. Strategies to optimize adoption are discussed.
Despite considerable investment in services, alcohol continues to pose a significant global health risk. In 2004, it accounted for 3.8% of deaths and 4.6% of disability-adjusted life years worldwide, with costs amounting to 1% of the gross domestic product of middle- and high-income countries (Rehm et al., 2009). Challenges in addressing alcohol-related problems are substantial-not least of which are its legal status, ubiquitous advertising (Smith & Foxcroft, 2009), and widespread approval of its use (e.g. only 21% disapproved of drinking in AIHW, 2008). While only 55% of men and 33% of women drink alcohol worldwide (Rehm et al., 2009), in many countries, drinking rates are higher. For example, 86% of Australian men aged 14 or over had at least one drink in the past year, as have 80% of women (AIHW, 2008). In the US, 58% of males and 47% of females aged 12 and over have had a drink in the previous 30 days, and an estimated 12.1 million US men (9.9% of the population) and 6.5 million women (5% of the population) fulfilled criteria for an alcohol use disorder at some time in the previous 12 months (SAMHSA, 2010). Rates of risky drinking are even greater: 31.6% of US men and 16.1% of women aged 12 or over had 5 or more drinks (≥ about 70 g ethanol) at least once in a 30-day period (SAMHSA, 2010); equating to nearly 60 million high-risk drinkers.
Currently, few affected people access treatment. In 2009, only 9.5% of US men and 7.5% of US women requiring treatment for alcohol abuse or dependence obtained specialist help (SAMHSA, 2010). Rates were particularly low for young adults (6.4%). A contributing factor in non-receipt of treatment is that many do not think they need it. In 2004–5, only 10.4% of people with alcohol disorders thought they needed treatment (Edlund, Booth, & Feldman, 2009). The issue is even more acute in young people: in 2004–5, people aged 18–25 were less than half as likely to perceive a problem than people aged 35 or more (OR = 2.09; Edlund et al., 2009). While binge drinking in young people presents significant short-term risks (Chikritzhs, Jonas, Stockwell, Heale, & Dietze, 2001), many negative impacts of alcohol take some time to emerge.
Attending a treatment service is also perceived as incurring significant cost: In the 2009 SAMHSA survey, 40% of people who needed alcohol treatment but did not receive it cited lack of health insurance coverage as a reason (SAMHSA, 2010). Inequitable access can arise from the impact of service costs across different socioeconomic groups. Emotional costs are also a factor: 10.7% of people not using services feared their neighbors' opinions and 12.7% thought that receipt of treatment might have a negative impact on their job (SAMHSA, 2010).
A further challenge for alcohol services is that affected people are widely dispersed. In 2009, 5.4% of people in completely rural areas of the US had alcohol dependence or abuse (SAMHSA, 2010). Practitioner/population ratios typically reduce with increased remoteness (DoHA, 2008), and many people outside population centers who require alcohol treatment have to travel long distances or endure extended waiting periods before accessing treatment. Telephone counseling or videoconferencing can help specialist services overcome geographical isolation, when managing alcohol-related harms (e.g. drink-driving; Mello, Longabaugh, Baird, Nirenberg, & Woolard, 2008) or offering aftercare (Lynch et al., 2010), but such services have yet to be routinely offered.
Even if these barriers were addressed, specialist services would have difficulty supporting the numbers of affected people: staffing, facilities and budgets would have to increase substantially. Nor would that guarantee access to high fidelity, evidence-based treatment. Use of these treatments is highly variable across services (Knudsen et al., 2003 and Miller et al., 2006), and significant gaps between science and clinical practice are apparent (Lamb et al., 1998 and Marinelli-Casey et al., 2002).
