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Journal of Substance Abuse Treatment, Vol. 11, No. 2, 131-135, 1994 pp. Coovrieht 0 1994 Elsevier Science Ltd P&ebin the USA. All rights reserved

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BRIEF REPORT

Emergency Physicians’ Ratings of Alcoholism Treaters

GRACE CHANG, MD, MPH,* BORIS M. ASTRACHAN, MD,? AND KENDALL J. BRYANT, PhDI#

*Division of Psychiatry, Brigham and Women’s Hospital and Department of Psychiatry, Harvard Medical School, Boston, Massachusetts;

tDepartment of Psychiatry, University of Illinois School of Medicine, Chicago, Illinois; SNIAAA, Rockville, MD. This work was initiated at the Department of Psychiatry,

Yale University School of Medicine, New Haven, Connecticut

Abstract- The purpose of this study is to identify treaters whom emergency physicians perceive to offer effective treatment of alcoholism. A random sample of 2,500 emergency physicians re- ceived a questionnaire comparing attitudes toward Alcoholics Anonymous (AA) and professional alcoholism treaters. Physician agreement on the efficacy of alcoholism treaters was greatest for AA (87%), moderate for mental health professionals (including psychiatrists and psychologists, 55%) and least for physicians and surgeons (excluding psychiatrists, 23%; chi-square = 1,024, p = .oooooooO5, df = 2). Physician education about other alcoholism treaters may be necessary if all types of treatment are to be considered for the emergency room patient.

Keywords-alcoholics anonymous; emergency physicians; emergency rooms; outpatient treatment.

INTRODUCTION

IN THE PAST DECADE, the treatment of alcoholism has expanded to include the services of the nonspecialist community health sector, the specialist alcohol prob- lem sector, and self help groups (Institute of Medicine, 1990). A sophisticated literature demonstrates the ef- ficacy of inpatient and outpatient alcohol treatment (Hayashida et al., 1989; Walsh et al., 1991). Industry has been active in establishing Employee Assistance Programs, which by seeking early identification and treatment of alcohol abusers, have been described as a driving force in the growth of alcoholism treatment (Walsh et al., 1991).

Yet physicians in office, clinic and hospital settings seem less clear about the importance of diagnosis and early intervention, and the effectiveness of treatment.

This project was supported in part by the BRSG Grant RR05358, awarded by the Biomedical Research Support Grant program, Division of Research Resources, National Institutes of Health.

Requests for reprints should be addressed to Dr. Chang, Divi- sion of Psychiatry, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115.

Although alcohol abusing patients have been estimated to use twice as many health care resources as those without alcoholism (Hankin & Oktay, 1979), physi- cians have been deficient in the early diagnosis of and intervention with alcoholic patients (Holden, 1985). For example, in one study revealing 47 motor vehicle accident patients with blood alcohol levels of 200 mg/dl or greater, not one patient was referred for alcohol treatment or evaluation (Chang & Astrachan, 1988). So, despite evidence that alcoholism treatment success rates can be as good or better than those for many medical problems, alcoholics are permitted to use hos- pitals as revolving doors, with the witting and unwit- ting complicity of institutions (Dans, 1987).

Explanations for the barriers to the diagnosis and treatment of alcoholism have included physicians’igno- rance about the disease; their attitudinal bias secondary to hopelessness, frustration, and sense of powerless- ness over alcoholism; and “medicalization” of a prob- lem they believe to be outside of their specialty area (Clark, 1981). Other explanations include reluctance to “stigmatize” patients, lack of awareness about treat- ment resources, and difficulties in gaining access to treatment services.

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132 G. Chang et al.

The purpose of this paper is to identify the treaters whom emergency physicians perceive to offer effec- tive treatment of alcoholics. It is hypothesized that by learning which treaters emergency physicians endorse, a better understanding of their referral patterns will emerge. This may have important implications for the overall treatment of alcohol abusing patients, since emergency rooms are appropriate sites for the screen- ing and early detection of alcohol use disorders (Sec- retary of Health and Human Services, 1990).

METHODS

Two thousand five hundred (2,500) physicians ran- domly selected from the 12,500 membership of the American College of Emergency Physicians (ACEP) were sent an anonymous, self administered, one time only questionnaire. The questionnaire, described else- where (Chang, Astrachan, Weil, & Bryant, 1992), con- sisted of two parts. The first part requested information on the respondent’s age, sex, year of medical school graduation, specialty, and practice setting. The second part probed attitudes toward alcohol treatment, alco- hol treaters, and management of alcohol impaired drivers using a Likert Scale for responses. The format allowed respondents to indicate the extent to which they agreed with each statement on a 7 point scale, with zero (0) being strongly disagree and seven (7) being strongly agree.

Several statistical analyses were used to assess the questionnaire results. Chi square tests were used in comparisons of alcoholism treaters. Correlations be- tween demographic and attitude variables were calcu- lated. Stepwise multiple regression analysis was used to analyze this nonexperimental data set with per- ceived efficacy of AA and other treaters as the depen- dent variables (Cody & Smith, 1987).

RESULTS

One thousand fifty five physicians returned the com- pleted survey, resulting in a response rate of 43%. The majority of respondents were male (83.3%) and the mean age was 39.6 years (SD = + 8.1 years). Re- spondents were from all geographic regions of the United States. About half worked in teaching hospi- tals (47.6%).

The main finding of this study is that 87% of re- sponding emergency physicians agreed that Alcohol- ics Anonymous (AA) is an effective treatment for alcoholism. In comparison, mental health profession- als, including psychiatrists, psychologists, and mental health workers, garnered 55% agreement and physi- cians and surgeons (excluding psychiatrists) received 23 % agreement (chi square = 1,024, p = .oooooooO5,

TABLE 1 Mean Responses to “Effective Treatment

of Alcoholics is Offered by.”

Treater N Mean SD

Alcoholics Anonymous 1049 5.45 1.40 Physicians and Surgeons,

Excluding Psychiatrists 1046 2.18 1.72 Psychiatrists 1041 3.47 1.75 Psychologists 1040 3.73 1.72 Other Mental Health

Professionals 1026 4.12 1.68 Composite of Psychiatrists,

Psychologists, and Mental Health Professionals 1024 3.77 1.51

Note: Range of responses to all categories, 0 to 7.

df = 2). Table 1 shows the mean responses to the ques- tion about who offers effective treatment of alcoholics.

Ratings of psychiatrists, psychologists, and mental health workers were highly correlated, with Pearson correlation coefficients ranging from .54 to .76 (p = .OOOl), and so a consolidated variable of mental health professionals was created. Physicians excluding psy- chiatrists were generally not perceived to be effective treaters of alcoholics and therefore were excluded from subsequent statistical comparisons.

Several demographic and attitude variables were re- lated to perceived efficacy of AA and mental health professionals on bivariate analysis. Higher propor- tions of physicians 40 years or older rated AA higher in comparison to the mental health professionals (chi square = 7.73, p = .005, df = 1). Higher proportions of respondents practicing in teaching hospitals, how- ever, favored mental health professionals over AA (chi square = 10.03, p = .002, df = 1). When respondents believed that alcoholism was a treatable illness, they perceived mental health professionals to be more effec- tive than AA (chi square = 18.55, p = .005, df = 1). Finally, when respondents believed that effective treat- ment resources were available in the community, higher proportions of mental health professionals were en- dorsed as effective in comparison to AA (chi square = 24.10, p = .0005, df = 1). Stepwise regression analy- sis supports these findings and will not be described separately. Figure 1 is a stem and leaf diagram dem- onstrating that physicians consistently endorse AA whether or not they perceive alcoholism treatment to be effective or available. It is noteworthy that per- ceived availability of treatment had no apparent im- pact on ratings of treaters, but perceived availability was related to perceptions of overall treatment effi- cacy. Of the 84.7% who thought alcoholism treatment is effective, 72.2% also agreed that treatment is avail-

Rating Alcoholism Treaters 133

Treatment Rating

*‘MH 75%

AA=MH 20%

MH>AA 5%

Treatment is Effective (n=lO47)

AA’MH 74%

AA=MH a%

MH>AA 4%

Treatment

Treatment Rating

AAsMH 75%

W=MH a%

MH>AA 2%

FIGURE 1. Stem and leaf plot of perceived efficacy.

AA=MH 23%

MHAA *%

able. On the other hand, of the 14.6070 who did not think that treatment is effective, only 47.7% agreed the alcoholism treatment was available.

DISCUSSION

The emergency physicians sampled overwhelmingly endorsed Alcoholics Anonymous, in comparison to mental health professionals, as effective treatment for alcohohsm. AA was the preferred treater, regardless of opinions on alcoholism treatment efficacy and avail- ability. Age (40+ years) and practice setting (nonteach- ing hospital) were associated with preference for AA. These associated factors may reflect lack of exposure to other effective forms of alcoholism treatment that are now available.

Limitations of this study include potential sample and response bias (Chaug et al., 1992). Although a ran- dom sample of 2,500 names was drawn from the 12,500 membership of the ACEP, it is possible that this sample may not be representative of emergency physicians as a whole. Nonetheless, the demographic and geographic profile of respondents is highly com- parable to that published about emergency physicians as a group (Eller & Pasko, 1988). While our response rate of 43% is typical for this type of survey (Oppen- heim, 1966), respondents with particularly strong opin- ions may be more likely to reply. However, it is unlikely that strong opinions about AA alone would have influenced return of the questionnaire since other information was sought. Inclusion of physicians from other specialties in subsequent studies would add to

134 G. Chang et al.

our understanding of physicians’ referrals to alcohol treatment.

The respondents’ preference for AA as the most ef- fective treatment for alcoholism is not yet consistently demonstrated by the scientific literature (Ogborne & Glaser, 1981; Glaser & Ogborne, 1982). In controlled studies of treatment, AA participation is not associ- ated with positive outcome; yet in descriptive studies, those choosing AA affiliation do better on outcome (Westermeyer, 1989). The difficulties in examining AA’s effectiveness -perhaps because AA is unscien- tific (Vaillant, 1983)-are well known. The potential bias introduced by selfselection of membership is sig- nificant. Alcoholics who chose to go to AA may have a greater motivation to work toward the goal of total abstinence, AA’s sole and unequivocal goal (Emerich, 1987). AA is reported to attract individuals with cer- tain personality characteristics or more severe alcohol problems (Ogborne, 1989; McLathie & Lomp, 1988; Seixas, Washburn, & Eisen, 1988). For example, in a 2-decade follow-up of male alcoholics after their first admis,sion for alcoholism treatment, only 7% attrib- uted their abstinence to AA (Nordstrom & Berglund, 1986). Yet among 100 respondents of 550 impaired physicians surveyed, AA was perceived as the most po- tent element in their recovery (Galanter, Talbott, Gallegos, & Rubenstone, 1990). Indeed, only a small percentage of alcohol dependent individuals ever be- come members (Emerich, 1989).

There may be many reasons why physicians prefer AA for their patients. The informal nature of referral to AA is easier than that necessary for more formal treatment, since it does not require extensive commit- ment or effort by the referring physician. AA meet- ings are widely available and do not require patient fees or insurance verification. The philosophy which insists that one must be a voluntary participant in treatment, that individual commitment to change is central, may to some extent relieve the practitioner from potentially unpleasant confrontations with a hostile patient in de- nial. AA offers an explanation for drinking, a prescrip- tion for recovery, and a new and sympathetic milieu (Emerich, 1989) for patients who are perceived to be difficult to treat. Finally, the limitations of AA are not as well known as its widespread reputation for success. Physicians may be endorsing AA on the basis of what they have learned informally, and may well be able to offer more informed referrals based on their firsthand experiences if they attend some open AA meetings.

The findings of this study of physicians in some way parallel those from a 1981 survey of 328 members of a middle class community in Chicago, whereby, in spite of understanding alcoholism as an illness, respon- dents remain largely unconvinced that professional or medical treatment is suitable (Rodin, 1981). Educat- ing emergency physicians about recent alcoholism treatment advances is necessary if they are to consider

and utilize all possible forms of treatment for their al- cohol abusing patients. Since no single treatment ap- proach can be effective for all patients with alcohol problems (Institute of Medicine, 1990), physician fa- miliarity with the potential benefits and limitations of all alcohol treatments may reduce their sense of frus- tration with the alcohol abusing patient and improve treatment outcome.

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