The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has released the Tenth Special Report to Congress on Alcohol and Health. The 492-page document highlights advances in research on genetic and environmental factors that can lead to alcohol addiction, as well as findings from studies on prevention and treatment. The report focuses on research conducted since 1997, when the Ninth Special Report was issued.

The report, which is divided into eight chapters, illustrates how alcohol researchers working in the fields of epidemiology, genetics, neuroscience, toxicology, prevention, and treatment are using the latest scientific tools and techniques to expand knowledge about alcohol addiction. It also documents the scope of alcohol's impact on society. The effects range from violence to traffic accidents to lost productivity to illness and premature death, which, according to the report, cost society $184.6 billion annually.

The eight chapters examine research on developmental views of drinking over the life span, the effects of alcohol on neural processes, genetic and psychosocial factors in alcoholism, medical consequences of chronic drinking, effects of prenatal exposure to alcohol, economic and health services perspectives, prevention, and treatment. Forty experts in these areas contributed papers, which were reviewed by a panel of more than 50 peer reviewers.

"Perhaps the single greatest influence on the scope and direction of alcohol research has been the finding that a portion of the vulnerability to alcoholism is genetic," writes NIAAA director Enoch Gordis, M.D., in an introduction to the report. Fifty to 60 percent of the risk of developing alcoholism is genetic, according to the report. Dr. Gordis attributes many of the advances in knowledge in the alcohol research field to the "spectacular" progress in the neurosciences over the past two decades.

The report highlights research on neural processes that underlie alcohol-seeking behavior and on how alcohol's actions in the brain are related to the phenomenon of addiction. The introduction to the chapter on neuroscience and neurobehavior notes that the Second Special Report in 1974 stated, "No one knows how alcohol intoxicates." The current report offers a detailed but still incomplete picture of the cellular effects of alcohol, including an examination of how alcohol slows the transmission of neural messages and how the brain responds to counter those effects. Other research highlights the effects of alcohol on gene expression and protein phosphorylation.

The chapter on prenatal exposure to alcohol summarizes advances in neuroimaging and cellular and molecular biology that have led to a clearer picture of the physical nature of alcohol-induced damage to the developing brain and the mechanisms that cause the damage. Imaging studies have demonstrated structural abnormalities in certain brain regions, whereas other regions seem to be spared. Researchers are now able to link deficits in cognitive and motor functions to the affected areas, and according to the report, they have a better understanding of what functions remain intact and why. The report notes that these findings have led researchers away from the earlier view that alcohol has global effects on the developing brain.

As noted in the introduction to the chapter on genetic studies of alcoholism, if alcoholism were determined by a single gene, the identity of the gene would likely be known by now. However, many genes play a role in vulnerability to alcohol dependence, and the task of pinpointing those genes is enormously difficult, as illustrated in the report. The chapter highlights research in the painstaking breeding of animal models to study drinking behavior. Findings from animal studies and twin and family studies suggest that only a few of the genes that contribute to alcoholism are known.

The chapter on medical consequences of alcoholism addresses liver injury; effects on the immune system, the cardiovascular system, and the skeletal system; and effects on women's health and on breast cancer. The chapter on prevention highlights community research that indicates that training of sales clerks in alcoholic beverage outlets and projects involving schools, parents, and communities can reduce underage drinking. The latest research on promising new medications in alcoholism treatment, such as acamprosate, nalmefene, and naltrexone, is summarized in the treatment chapter.

The report can be downloaded from the NIAAA Web site at www.niaaa.nih.gov. Bound copies of the report can be ordered by writing to NIAAA, Publications Distribution Center, P.O. Box 10686, Rockville, Maryland 20849-0686.

A two-year effort led by the Center for Substance Abuse Treatment (CSAT) has resulted in a consensus report that presents recommendations for improving the way in which alcohol and drug treatment services are delivered and paid for. In releasing the report, entitled Changing the Conversation: Improving Substance Abuse Treatment, CSAT officials said that it offers a set of guidelines and recommendations that can lead to the goal of making effective treatment available to all who need it. According to the report, between 13 and 16 million people need treatment in any given year, but only 3 million receive care.

The report, which calls for development of commonly accepted standards for what constitutes effective substance abuse treatment, is based on relevant research, consultation and discussion among five panels of experts representing a cross-section of opinion and experience in the field, and input from consumers who attended six regional public hearings and offered comments on a CSAT Web site.

The panels addressed key persistent issues in five areas—closing the treatment gap, reducing stigma and changing attitudes, improving and strengthening treatment systems, connecting services and research, and addressing workforce issues. The participants agreed on five overriding principles that encompass the specific recommendations of the panels.

• Invest for results. The report calls for the wise use of resources through investment in effective services. Recommendations include closing the gaps in treatment capacity, establishing standard insurance benefits for both private and public insurance that ensure parity with coverage for other medical conditions, and setting reimbursement rates and funding levels to cover reasonable costs of providing care, including the adoption of evidence-based practices and care for persons with no insurance.

• No "wrong door" to treatment. The panelists agreed that all systems of care must ensure that persons in need of treatment will be identified and assessed, no matter where they enter the system. One recommendation in this area is the widespread adoption of an evidence-based model for the continuum of care across health, human services, and justice systems, including the substance abuse specialty sector.

• Commit to quality. The report calls for a commitment to ongoing improvement in the quality of care. It recommends a system that more effectively connects research and practice and that promotes communication and collaboration between service providers, academic institutions, and researchers. The report encourages the treatment field to define evidence-based practices and outcome measures; establish standards for education, training, and credentialing; and adopt best business practices for program management and operations.

• Change attitudes. The panelists agreed that reducing stigma will require a concerted effort based on systematic research. It recommends that the treatment field engage the recovery community in discussions to better understand multiple and overlapping forms of stigma. The report calls on researchers to more carefully examine the views and attitudes of various population groups, and it directs professionals to develop educational initiatives that promote the dignity of people in recovery.

• Build partnerships. The report encourages more effective efforts by substance abuse treatment professionals to unite people in recovery, including their families and friends, and to bridge state and local systems of care. It calls for the creation of a partnership support program that provides financial and other support to collaborative projects and groups.

The panelists and other participants also developed action steps for implementing the national treatment plan. CSAT has chosen to focus on ten recommendations for which it has both the authority and resources, according to the report. They include developing a standard insurance benefit package and conducting marketing research to provide the foundation for a social marketing plan designed to reduce stigma.

Changing the Conversation: Improving Substance Abuse Treatment is available at www.natxplan.org. It can also be ordered free of charge from the National Clearinghouse for Alcohol and Drug Information by calling 800-729-6686 or 301-468-2600 or visiting the clearinghouse Web site at www.health.org.

The National Association of Psychiatric Health Systems (NAPHS) has released the results of a member survey indicating that inpatient admissions remained strong in 1999. A typical hospital in 1999 saw 1,831 inpatients, an increase of 4.9 percent over 1997. Medicaid and Medicare admissions accounted for 40.9 percent of all admissions. Inpatient occupancy rates increased 14.3 percent, from 54.5 percent in 1997 to 62.3 percent in 1999. The average hospital length of stay for all groups was 10.2 days in 1999, the same as in 1997. Median lengths of stay continued to decline, from 9.4 days in 1997 to 9.2 days in 1999. The report attributes the decline to a "dramatic shift" in the role of hospitals toward the stabilization model. It points out that inpatient facilities have focused on treatment approaches that respond to payers' increasing demands for shorter stays, lower costs, and expanded access to care.

At the same time, outpatient care has not grown to the degree necessary to adequately provide care to the most severely ill patients, the report notes. Partial hospital programs admitted an average of 507 patients in 1999, up slightly from 504 in 1997. A typical outpatient facility saw 1,390 persons in 1999, a decline from 2,080 in 1997. However, the average number of outpatient visits per facility increased 6.8 percent over the same period, from 19,027 visits in 1997 to 20,332 in 1999. The average number of outpatient visits per patient increased to 12.4 days, from 9.8 days in 1997.

The report was based on the responses of 104 psychiatric facilities owned and operated by NAPHS system members. The NAPHS Annual Survey Report: Trends in Behavioral Health Care Systems: A Benchmarking Report is available for $400 from NAPHS, 325 Seventh Street, N.W., Suite 625, Washington, D.C. 20004-2802; 202-393-6700, ext. 15.