AUSTRALIAN ALCOHOL/DRUG REVIEW, VOL.3, NO.2, JULY 1984

P R O F E S S I O N A L D E V E L O P M E N T : CAREER P R O S P E C T S

*R.G. POLS

Abstract The need for more manpower resources in the area

of alcohol and drug-related problems is established. It is argued that growth of clinical services, public policy

initiatives, health educational strategies, as well as research in all these areas, will occur in the medium term. Cautious optimism is expressed.

Introduction Pat O'Neil contrasted Prof. Griffith Edwards' contribution to our second annual conference, to that of our own on the lack of professionalism.

"We started today with part of the military overture, followed by the most magnificent rendition I have ever heard by the imported baritone. I was also encouraged by the fact that the quafity and content of the local song we have heard is very similar, albeit by his name and Welsh extraction he is particularly good at Eisteddfods. What was different was that he is a full-time professional in the field that we all singing about as enthusiastic amateurs. Perhaps we haven't yet achieved enough professionalism in this country.... ,,1

Whilst this could be debated, the thrust of this paper will be in much the same direction. That is, career prospects will continue to improve in the area of addiction behaviour, only if our professionalism does so. Credibility as authoritative professionals is a necessary precondition for the expenditure of public funds, especially in these times of economic restraint.

It will be argued that there is a need for more manpower, that this need has been recognized but that in spite of this, few manpower positions have been' forthcoming. Some reasons for this wilt be explored.

WHAT NEED IS THERE? Since 1975 a steady accumulation of formal enquiries

have documented unmet needs which are costing the Australian community very large sums indeed. The Baume report pointed out the costs of alcohol abuse in 1976. 2 The Sackville Royal Commission into the Non- Medical Use of Drugs discussed a large range of issues 3-'' and documented the need for changes in community attitudes, information and improved services in 1979. The Williams Committee reviewed the area from a wider perspective in 198018 and in 1981 Senator Waiters, as chairperson of the Senate Standing Committee on Social Welfare, reported on the use of prescribed medications. Quite apart from these formal enquiries, there have been many clinical studies in Australia 2°-2' and elsewhere =~-2a which have documented the prevalence of alcohol related problems within general hospitals. Professional bodies have also expressed their concern regarding alcohol-related problems: "-~' clearly there is a need.

HOW SHOULD THIS BE MET?

There are currently three differing and complementary approaches to this need, which unfortunately are often perceived as being competitive by their respective practitioners. They are the traditional clinical approaches, the public policy approach and the health education approach to addictive behaviour.

TRADITIONAL CLINICAL APPROACHES These include medical, psychological and social

strategies. When such strategies have been evaluated 32-~' there is little consistent data to recommend one approach over and above the other.

Some factors that appear to correlate consistently with good outcome are: social support, 3'-3' motivation, 3s abstinence for six months ~ and specific goal setting regarding abstinence or controlled drinking, taking into account age, sex and marital status. '°,''

Some factors also appear to have face validity, when considering clinical intervention. These include: earlier diagnosis and intervention so that less social disruption has occurred; increasing motivation through diversionary or industry programmes, 42 thorough assessment and the planning of individualised strategies.

Traditional clinical interventions deal with individual patients and are costly in terms of time, beds and manpower. Unless it can be shown that such interventions have a specific effect, which is better than simpler and less costly supportive approaches, then such intensive inpatient treatment approaches will not be given continuing support by governments and will become low- key rehabilitative or supportive services.

It would appear theat there is considerable urgency for some of the methodological problems of previous evaluation studies to be addressed, if the clinical approach is going to be continued to be supported. Before studies using case control or randomised methodologies are done, a more fundamental need is apparent, that of an agreed nomeclature. Until alcohol use is defined in operational terms and the presence or absence of the Alcohol Dependence Syndrome, ̀ 3." family history 4s and detailed drinking behaviour are routinely documented, such evaluation studies cannot be adequately done. As a result, any treatment effects are likely to be lost in view of the multiplicity of variables that probably exist in all forms of alcohol and drug problems and the credibility of traditional clinical programmes will remain low.

In summary, the clinical approaches that seem to have face validity at this stage of our knowledge include: the treatment of the medical complications of drug abuse; detailed assessment of patients with drug-related problems; 37 routine screening of all patients presenting

Director of treatment Services, Alcohol & Drug Addicts Treatment Board of South Australia, 1st Floor, 3/161 Greenhill Road, Parkside, SA 5063.

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to hospitals with drug abuse; ".'e medical or non-medical detoxification; counselling of patients and other health care staff involved in their management; the arrangement of follow-up of more than six months, including the provision of effective support and specific treatment planning with the spouse. Such a mental health consultation 4z and liaison model '~ would appear to be an appropriate direction at this time. Day patient care should also be explored as an alternative to inpatient treatment.

The role of clinicians as clinical teachers should also not be underestimated. The specific clinical skills required for the management of patients who have a chronic relapsing lifestyle syndrome involving the use of a drug, need to be taught to all health and welfare professionals. The recognition of this area as a valid area for clinical practice will gradually grow. Within the private sector there is a great clinical need for practitioners who have expertise in this area and this has been addressed by Dr.G.Wilson. '~

THE PUBLIC POLICY APPROACH Government action consequent upon the various

reports regarding alcohol and drug abuse have consisted of the creation of a number of national committees addressing alcohol abuse, tobacco products and th~ National Drug Education Programme (NDEP). Nationa, committees with State representation are shown in Fig 1. They consist of the Health Committee on Drugs of Dependence (HCDD), the National (Standing) Committee on Alcohol and the National (Standing) Committee on Tobacco Products. The HCDD is also responsible for the National Drug Education Programme through its Subcommittee on Drug Education. Further more, a number of programmes have been initiated. They are (Fig 2) the Alcohol in Industry Programme administered through the Australian Foundation on Alcoholism & Drug Dependence (AFADD), the sponsorship of research into the epidemiology of the Wernicke-Korsakoff syndrome through the National Health & Medical Research Council (NH & MRC) Standing Committee on Public Health and the funds provided for research into the early stages of alcohol abuse.

FIGURE 2 SOME RESPONSES

(1) National Drug Education Programme (NDEP) (2) Alcohol in Industry Programmes (AFADD) (3) Epidemology of Wernicke - - Korsekoff

Syndrome (NH & MRC) (4) Early Stages of Alcohol Abuse (NH & MRC) (5) Tightened Drink-Driving Legislation (6) Price Differential for Low Alcohol Beer.

So far these initiatives have seen a number oT significant results. These include the development of some drug education programmes, the alcohol in industry programme, the campaign to restrict tobacco advertising and the proposed tightening of alcohol advertising.

The HCDD is attempting to grapple with the implementation of the Williams Report.

Independently, States have addressed and tightened drink-driving legislation and a licence fee differential for low alcohol beer has been created in South Australia s° and Victoria.

These relatively independent initiatives represent initial responses More sophisticated responses are required, as has been clearly documented by the National Institute on Alcohol Abuse & Alcoholism (NIAAA) Expert Committee Report. sl Such responses include the provision of much more adequate data on which to base policy decisions.

An even more recent initiative is the proposed establishment of a National Institute on Occupational Health. s2 Alcohol in Industry co-ordinators should make their presence felt in such a forum.

Although these responses have occurred, they are piecemeal and grossly inadequate. It seems likely that public policy advisors will emerge over the next decade as it becomes increasingly apparent to Governments that more rational and more sophisticated approaches are needed. With this will come an increased need for monitoring, evaluation and the provision of technical information required for policy development.

FIGURE 1 NATIONAL COMMITTEES

l AUSTRALIAN HEALTH MINISTERS' CONFERENCE

STANDING COMMITTEE OF AUSTRALIAN HEALTH MINISTERS

I ON 1 I DRUGS OF DEPENDENCE I

t I o. I /D.UG EDUCAT,ON I

NATIONAL STANDING COMM TTEE ON ALCOHOL

NATIONAL STANDING COMMITTEE ON

TOBACCO PRODUCTS

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THE HEALTH EDUCATION APPROACH

Clinicians working with people who have alcohol and drug-related problems have responded to community needs for information and the need of their clients for services, by doing educational programmes with various interested groups. Often these were "one off" and used "scare tactics"; often they overstated issues or the effectiveness of treatments. They were the initial educational approaches and much individual face to face community education is still being done.

More recently, Governmental authorities have seen the need for educational programmes for the public at large, for relatives of people with drug-related problems and for school children. The National Drug Education Programme and the concern about alcohol-related traffic accidents 53.S' are factors which have led to a significant thrust towards community education. School programmes are being developed, as are general lifestyle programme which include the reduction in consumption of drugs as their aim.

Mass educational approaches have also been advocated. One such programme in the United Kingdom ss consisted of G.Ps advising their patients to stop smoking with or without giving them a simple stop smoking leaflet. The effect of giving the leaflet was a 5% reduction in cigarette smoking in the population so counselled. What was pointed out, however, was that if all G.Ps in the United Kingdom did the same, the total effect would be equivalent to the effect 5,000 stop- smoking clinics would have at considerably less cost. Although there is a shift from face to face education to mass education, including that via the electronic media, it is also clear that such mass programmes still reach relatively few people and that a combination of media face to face education and counselling and ongoing support se was the most effective method to achieve sustained behaviour change in consumption habits..

Drug educators are clearly needed, not only to assist in the development of such programmas, but also in the area of professional education. This is particularly so for professional continuing education. Health and welfare professionals cannot remain up to date without additional assistance, as the volume of information continues to escalate. This is no different in the area of drug-related problems.

Thus career prospects should be bright for health education teachers, drug educators involved in the production of resources, media professionals, those involved in the education of professionals and the development of information services on which the health education profession depends.

ARE THE RESPONSES ADEQUATE? The simple answer is clearly no. In reality there is little

well qualified manpower in Australia to adequately deal with any of the three approaches to drug-related problems. As Opit has pointed out sz, there are insufficient psychiatrists in the drug abuse area and it is likely that a similar deficiency exists in all professional discipline involved in the area.

The development of professional training programmes is of considerable importance. The course at the Macquarie University, ss the Phillip Institute s9 from next year and the upgrading of the Western Australian

Institute of Technology (WAIT) courses are encouraging, so Undergraduate programmes remain less than adequate. Until such time as drug abuse is an integral and important component of such undergraduate programmes, this area will continue to have low status for its patients and practitioners.

The establishment of an intercollegiate working party, sponsored by the Australian Medical Society on Alcohol & Drug-Related Problems (AMSADRP) is an important step in the elevation of the status of medical practitioners in this area of practice. The Royal Australian College of General Practitioners, the Royal Australasian College of Physicians and the Royal Australian & New Zealand College of Psychiatrists are working to establish a common core curriculum for trainees who would be able to complete alcohol and drug electives during advanced training. An advantage of such a curriculum is to open some alcohol and drug service units to rotating trainees, bringing such units back into mainstream medical training programmes. Similar training programmes should be established for all health and welfare professionals wherever possible and the development of the above courses will hopefully do this.

WHAT ARE THE IMPLICATIONS FOR CAREER PROSPECTS?

It is somewhat like gazing into a crystal ball to attempt to answer such a question. However a number of important issues are clear "

• There is a need • The need has been recognized • The responses are less than adequate to meet the

need. • There are complementary approaches to the

problem The conclusion should be that career prospects are

good for all these complementary areas. Why then has there been such a tardines in the development of manpower positions? Doctor behaviour is one aspect of this paradox of high prevalence and low clinical recognition and service provision, which have been argued elsewhere. 61 The cultural attitudes of administrators and legislators also effect decision making regarding resource allocation. Double standards clearly exist in our culture s2 and this leaves tainted both the patients and their attendants with moral judgements made by a large proportion of our community. Drinking, for example, is a "naughty but nice" activity which, although damaging, is condoned, until people are caught, behave in extreme or offensive ways or when it produces gross disability. Then also, and perhaps most importantly, there are the powerful liquor and advertising industry lobbies, retarding rational approaches to these problems.

A further problems is the lack of effective advocacy and publicity regarding alcohol and drug-related problems. Change must occur if more appropriate levels of funding are to be directed into this area.

SOME POSSIBLE STRATEGIES

THe strategies also fall into the clinical, educational and legislative areas.

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The creation of awareness in specific target groups: The general hospital professionals are one such target

group. The measurement of the extent of drug consumption is a useful way of educating the hospital community and establishing the need for a service at the same time. z',"

Submissions to legislative reviews: Whenever enquiries occur regarding issues to do with

the effects of advertising standards, liquor licensing or traffic accidents, advantage should be taken to present an objective factual review of the pertinent issues. Changes enacted in legislation can have far-reaching effects.

Public advocacy:

The many voluntary organisations dealing with clients with drug-related problems should speak much more clearly and with one voice. The Australian Consumers' Association and the Australian Foundation on Alcoholism & Drug Dependence should be encouraged to become much more involved in this process.

Research The monitoring of disability and consumption and the

demonstration of their association, is painstaking but must be done. Economists will strive for policies that reduce costs, but only if the economic benefits provided by the industry can be compensated for.

WHAT OF THE FUTURE? The response to drug-related problems will be slow but

steady, as our community becomes better acquainted with the facts regarding the morbidity and mortality associated with drug use. Attitude change will follow and greater resource allocation will be a part of this.

Professional interest in the area will grow more rapidly as courses are provided. The medium term outlook is good.

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