Drug and Alcohol Dependence, 26 (1990) 93- 102 Elsevier Scientific Publishers Ireland Ltd.

93

The role of alcohol-related problematic events in treatment entry

Connie Weisner

Institute of Epidemiology and Behavioral Medicine, Medical Research Institute, 1816 Scenic Ave., Berkeley, CA 94709 KJi3.A.I

(Received August lOth, 19881

This is an analysis of alcohol-related problematic events experienced by alcohol treatment clients in the year before treat- ment and the reporting of these events as major reasons for treatment entry. A probability sample of new intakes W = 3161 of the 8 contracted alcohol programs of a California county was interviewed. Data were collected on demographics, drinking pat- terns and a series of ten problematic events. Events W = 9821 are the unit of analysis. The analysis examines the events

reported as major reasons for entering treatment. Logistic regression is used to investigate the socio-demographic and drink- ing variables associated with that reporting. Drinking driving, relapses and serious drinking episodes were reported as being major reasons for entering treatment a significant proportion of the times they occurred. Public drunkenness and non-traffic accidents had significant proportions of individuals reporting them as not being major reasons for treatment when they

occurred. Age, gender, ethnicity, marital status, employment and frequency of drunkenness were predictors of some types of events being major reasons, but there was no pattern across all events. The variables associated with experiencing an event were not the same as those which predicted the event would be reported a major reason for treatment.

Key words: alcohol treatment; alcohol problems; treatment entry

Introduction

During the past decade, many changes have occurred in public attitudes, as well as in social policies, related to alcohol treatment. Along with an increase in the attribution of many social and health problems to alcohol, treat- ment entry in both public and private programs has come to be associated with the occurrence of specific types of problems. While treatment models focus on alcoholism as a progressive disease, programs target populations with alco- hol problems specific to job performance, domestic violence, crime and many other social ills in an effort to bring individuals to treat- ment earlier than in the past [l-4]. Changes in the process of coming to treatment congruent with this new problems approach in treatment recruitment largely have been ignored in alco- hol research examining help-seeking behavior and treatment entry.

The concepts useful for understanding treat- ment entry from a perspective of alcohol- related problematic events come from both general health services and alcohol research. In the health services literature, Zola [5] described occurrences of critical incidents or “cues”. He argued that while people frequently have symptoms that might be interpreted by health professionals as relevant to disease and treatment, those which are acted upon by the individual are those which have been defined by others as relevant for action. In the alcohol literature, Jellinek [6] included examples of problems or problematic events as indices of the phases of alcoholism (for example, work, money and physical problems). Markers of the disease concept as well as indicators of alcohol dependence include symptoms associated with problematic events as well as those related to withdrawal and tolerance [7]. Alcoholics Anony- mous (AA) has described the process of getting

0376-8716/90/$03.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

94

help as one where increasing areas of an individual’s life become ravaged by problems until he or she “hits bottom”, a phenomenon usually characterized as an event having a strong impact on the individual.

Studying the events that lead individuals to treatment increases understanding of the types of medical problems and behavior which indi- viduals, institutions and society in general define as in need of treatment. This knowledge is important for improving prevention activi- ties and developing intervention strategies. On an individual level, some types of events may be sufficiently severe that their occurrence is reason alone for someone to decide to go to treatment. For example, an injury in a drink- ing-related household accident may cause an individual to be concerned about his or her drinking and decide to get help. On a policy level, certain events, regardless of their isola- tion from any others, are targeted as serious enough to require treatment. Previous studies have considered the relationship between the saturation of life areas with problems and treatment entry [8] and the intrinsic character- istics of problematic events-whether the con- text or responses to problems is important in triggering treatment entry [9]. This paper investigates the relationship of different alco- hol-related events to treatment entry and the socio-demographic and drinking correlates of the reporting of those events as major reasons for treatment entry.

Methods

Sample The present study is part of the Alcohol

Research Group’s Community Epidemiology Laboratory underway since 1980. As part of the overall study, data were collected from consec- utive admissions to 8 alcohol programs in a northern California county. The sample con- sists of 316 clients from three Detox programs W = 173) and 5 Recovery Homes UV = 143)a.

“The larger study included probability samples from the drinking driving programs in the county as well W = 431).

These samples are not included in this analysis.

The sample represents the entire public sector of the county’s alcohol treatment capacity, with the exception of its drinking driving programs. All programs are contracted to non-profit cor- porations which accept fee-paying, as well as indigent clients, and two detox and two recovery home programs have employee assis- tance contracts with industries in the county. Thus there is a mix of publicly and privately funded clients within the sample.

The gender distribution in the sample was 81% male and 19% female. Thirty percent of the sample was between ages 18 and 30; 42% was between ages 31 and 45 and 28% was aged 46 or older. Sixty-two percent identified them- selves as White, 19% as Black and 8% as His- panic. Only 22% of the sample reported being married or living together in a marriage-like relationship. Twenty-four percent of the sam- ple was employed when entering treatment. Sixty-two percent reported a household income of less than $10,000 and 16% reported one between $10,000 and $20,000. Seventy percent of the sample reported drinking alcohol nearly everyday. Forty-five percent reported drinking 12 or more drinks on an occasion nearly every- day.

Recruitment of clients did not differ substan- tially for the different types of programs. In both detox and recovery home programs there was a mix of legal coercion and personal preference or non-legal pressure. There was no official program operating in the county whereby public inebriates were diverted to detox, although occasionally this occurred informally. (Seventeen of the 117 clients who had been picked up for public drunkenness in the past year had been taken to detox by the police). There were similar patterns for detox and recovery home admissions in the level of coercion. For example, of those reporting a criminal arrest in the 12 months prior to treat- ment 0.7 = 52) 1 in detox and 3 in recovery reported having been given a choice of jail or treatment; none in detox and 3 in recovery reported having been told to go to an alcohol program without choice; and one in detox and 2 in recovery reported having been told by a criminal justice representative or attorney that

95

if they completed an alcohol program it might do them some good at sentencing. Finally, for those with alcohol-related job events W = 471, 10 in detox and 24 in recovery reported that their boss or someone in the personnel depart- ment suggested they go to alcohol treatment and 3 in detox and 6 in recovery reported that participation in the program was a condition for keeping their jobb.

Procedures

Independent samples were drawn from each of the programs from official daily intake records. A l-h in-person interview with a structured questionnaire was conducted by trained interviewers independent from alcohol program affiliation. Individuals were sampled and interviewed soon after intake to minimize the influence of the program on their respon- ses. The response rate was 83%. A weighting scheme was constructed accounting for time differences in sampling and categories of non- response across programs to allow for analysis of the sample aggregated and by program type. There are only minor differences between the unweighted and weighted data [lo]. Thus, unweighted data are usedc.

Measurement Three main categories of variables were ana-

lyzed: socio-demographic characteristics, meas- ures of drinking patterns and alcohol-related problematic events. Alcohol-related events W = 9821 rather than individuals are the unit of analysis for this study. The median number of events reported by individuals in each type of program was 3. Chi-square tests and tests of proportion found no significant differences between individuals above and below the

bThe drinking drivers in the sample are not those who were enrolled in the County’s mandated first and second offender

programs. This sample includes only these DUIs who were in the county’s nonDU1 programs. Most were entering treatment in addition to receiving legal sanctions.

<‘See Weisner and Cameron, [lo] for a description of the Community Epidemiology Laboratory, the programs in the study, sampling frames, completion rates, non-response analysis and weighting schemes.

median for measures of sex, age (18 - 30130 + 1, marital status, (married or living together/not married or living together), ethnicity, employ- ment, income and education.

The use of events to measure reasons for treatment entry also was an attempt to under- stand what lies behind the strong cultural bias to say “I just got fed up and decided to go to treatment”. Pretest subjects who would say that would also report some incident when asked whether anything specific had happened this time. In spite of some individuals having had a build up of problems, with very few exceptions there was some event that acted as a final pushd.

The process of developing the list of proble- matic events entailed reviewing the literature, interviewing treatment providers, collecting open-ended histories from clients of process- decisions involved in going to treatment and finally, pretesting lists of problematic events experienced in the 12 months prior to treat- ment on 50 clients from different types of pro- grams. The list was designed to cover as broadly as possible the range of events that might lead to treatment”. Most of the events were specific interactional events, either with family and friends or with some formal or infor- mal community gatekeepers or institutions. Two events can be considered “drinking reali- zation” events, since pretests showed that respondents often defined relapses or certain serious drinking episodes as events. For exam- ple, it was common for pretest subjects to claim that they had come to treatment because of “falling off the wagon” which had made them realize they couldn’t handle their drinking on their own, or because of having “a scary case of D.T.‘s” or similar experience that had greatly disturbed them. The events were:

din the general health services literature, Anderson [ll] discusses the methodological advantages of studying events, since it “focusses memory on a specific event and resulting behavior rather than requiring unprompted recall of all illnesses and help-seeking efforts” (p.4181. *While the list was intended to be exhaustive, respondents

were only asked to rate each event in regard to whether it was a major reason for entering treatment. When they were asked for the most significant reason, they were given an open-ended alternative as well.

96

(11 Were you arrested for drunk driving? (21 Did the police pick you up for public drun- kenness? (3) Were you arrested for anything else (other than public drunkenness or a traffic offense)? (4) Did you have a traffic accident while you were driving? (51 Did you have any other sort of serious acci- dent in which you were injured or had a close call? (61 Did you have any serious arguments with family members or others close to you about your drinking or the effect your drinking was having on those around you? (71 Did your boss or supervisor make serious complaints about your work or attendance at work? (8) Did a doctor or health worker tell you that you had serious problems connected with your drinking? (9) Did you start drinking again after a period of abstinence?-1 mean when you had made it a point not to drink anything at all? (This refers to a time period of at least 1 month when the respondent was not drinking on his own voli- tion). (10) Did you have a blackout, D.T.‘s or a particu- larly heavy drinking occasion that alarmed you? (As a follow-up, the respondent is asked whether it was a blackout, D.T.‘s,

hallucinations, a particularly heavy drinking occasion, or something else).

Respondents were asked a set of follow-up questions for the last occurrence of each type of event reported. These included questions on the involvement of alcohol in the event and whether the event was a major reason for going to treatment. Only alcohol-related events are included in this analysis. The dependent varia- ble is whether an event was reported to be a major reason or not a major reason for treat- ment. The time frame is the 12 months prior to treatment entry. This time frame has been commonly used in surveys of drinking patterns and problems. In this case it was considered long enough to see patterns and responses regarding treatment entry to different types of events by clients, as well as accumulation of

types of events. At the same time it was short enough to minimize problems with memory of events.

Data analysis For each type of event, sample proportions

for those events reported as major reasons for treatment were compared with sample propor- tions for events not reported as such [12]. Logistic regression was then used to analyze the predictive value of gender, age, ethnicity, marital status, education, income, employment and frequency of drunkenness on the reporting of events as major reasons for treatment’. The predictor variables are dichotomous variables, with those listed on Table 3 coded as 1 and their opposite coded as 0. The dependent variable is a dichotomy with major reason for treatment coded as 1 and not a major reason for treatment coded as 0.

Results

Characteristics of events There was large variation in the distribution

of events reported (Table Il. The relapse event was most often reported in the sample, fol- lowed by serious drinking episodes and serious family problems. There was also variation in the characteristics of those reporting the differ- ent types of events. While the gender breakdown was similar across most events, proportionally fewer women reported alcohol- related traffic accidents, public drunkenness and job confrontation. Criminal arrests and traffic accidents were reported in highest pro- portions by the youngest age group. Health and relapse events were reported in highest pro- portions by the oldest age groups. While differ- ences by ethnicity were not as large, job events were reported in larger proportions by Whites than were other events. This may at least par- tially reflect their higher level of employment

‘The program used for the logistic regression is the Probit proceedure of SPSSx [13]. The model estimated by this pro- gram is LOGIT (~112 + 5 = a + bx. To calculate the odds ratio using this model the logistic coeffient is multiplied by 2 and the natural antilogarithm of this number is taken.

Tab

le I

. D

emog

raph

ic

char

acte

rist

ics

and

drin

king

pa

ttern

s by

alc

ohol

-rel

ated

ev

ents

(p

erce

nts)

. _ D

rink

ing

Publ

ic

Oth

er

Tra

ffic

O

ther

Se

riou

s Jo

b H

ealth

R

elap

se

Seri

ous

driv

ing

drun

k cr

imin

al

arre

st

acci

dent

ac

cide

nt

fam

ily

prob

lem

co

nfro

nt-

atio

n co

nfro

nt-

atio

n dr

inki

ng

epis

ode

N

Gen

der

Mal

e Fe

mal

e

Age

18-3

0 31

-45

46 a

nd o

lder

M

arita

l St

atus

M

arri

ed/li

ving

to

g.

Div

orce

d/se

para

ted

Wid

owed

N

ever

m

arri

ed

Eth

nici

ty

Whi

te

Bla

ck

His

pani

c O

ther

E

duca

tion

Som

e H

S or

les

s H

S gr

adua

te

Som

e co

llege

C

olle

ge g

rad

Inco

me

Und

er

$300

0 $3

000

- $9

999

$10,

000-

$1

9,99

9 $2

0,00

0 -

$34,

999

$35,

000

and

over

D

rink

ing

Nea

rly

ever

y da

y G

ot d

runk

ne

arly

ev

ery

day

(74)

(1

17)

80

89

20

11

37

34

42

48

22

18

23

15

42

44

3 3

32

39

76

71

11

20

7 8

7 2

30

30

31

36

31

30

8 4

14

29

25

26 6 57

32

45

33

10

12 1 40

50

- (5

2)

(15)

77

93

23

7

60

53

31

40

10

7

23

13

29

47

0 0

48

40

67

67

15

7 12

20

6

7

40

40

33

33

23

20

4 7

39

20

31

33

12

13

12

27

6 7

17

80

52

40

(45)

(1

43)

78

22

78

22

40

36

49

45

11

19

18

30

53

44

0 0

29

26

76

74

13

16

11

6 0

4

36

22

31

34

27

34

7 10

47

31

33

27

5 18

16

19

0

6

82

51

74

45

(47)

(1

17)

92

78

9 22

40

23

49

46

11

31

23

15

49

52

0 2

28

31

83

72

9 16

4

6 4

6

28

28

45

32

23

30

4 10

33

34

22

37

17

11

20

11

9 6

79

81

53

53

(195

) (1

77)

79

21

79

21

28

35

42

46

30

19

20

19

46

44

4 2

30

35

71

68

17

19

8 9

4 4

22

27

34

32

34

35

10

6

29

32

33

35

15

13

19

16

4 4

69

75

36

47

98

Table II. Frequency of events and frequency of reporting events as major reason for treatment.

Fre- quency

of events

Proportion Proportion of events of major

within reasons event when sample event

reported

Drinking driving Public

drunkenness Other criminal

arrest Traffic accident

Other accident Serious family

problem Job problem

Health Relapse Serious drinking

episode

74 8 73* 117 12 31*

52 5 37

15 2 27

45 5 24* 143 15 48

47 5 64

117 12 49 195 20 65* 177 18 66*

P < 0.05. Tests of statistical significance were based on comparing population proportions, the unpaired case (Armi-

tage, 1971).

within the sample. Public drunkenness, serious drinking episodes, relapse, health-related events, serious family problems and criminal offenses were reported in higher proportions by Blacks than were other events. Other crimi- nal offenses, traffic accidents and non-traffic accidents were more frequent among respon- dents in the lowest educational group than other events. Serious family problems, drink- ing driving, criminal arrests and work confron- tation events were reported in higher

proportions by individuals who were married or living with someone in a marriage-like situa- tion than were other events.

There were major differences in income dis- tributions across events. Traffic accidents, drinking driving and work related events were more commonly reported by individuals with incomes over $20,000 than were other events. In contrast, non-traffic accidents, public drun- kenness and other criminal arrests were

treported in larger proportions by individuals in the lowest income bracket.

Drinking patterns Large differences were found across events

for measures of drinking nearly everyday and getting drunk nearly everyday (Table Il. Over half of those reporting all events except crimi- nal offense and public drunkenness, reported drinking nearly everyday. Frequency of drun- kenness nearly every day was reported less frequently by respondents reporting drinking driving and relapse events than among those reporting other events. Across all events, respondents reported getting drunk nearly everyday less frequently than they reported drinking 12 or more drinks on an occasion (not shown), suggesting that they considered quantities in excess of 12 drinks necessary to cause drunkenness.

Events as major reasons for treatment There was large variation in the proportion

of times that each type of event was reported to be a major reason for treatment when it occurred (Table II). A significant proportion of individuals reporting drinking driving, serious drinking episodes and relapses considered those events to be major reasons for treatment entry when they occurred. On the other hand, a significant proportion of public drunkenness and non-traffic accident events were not reported as major reasons for treatment entry when they occurred.

Prediciting major reason for treatment entry Logistic regression was used to examine the

relationship between socio-demographic and heavy drinking variables and whether an event was reported to be a major reason for treat- ment entry. Table III presents the logistic coef- ficients, standard errors and odds ratios for each variable. The serious family problem, criminal offense, health, work, relapse and seri- ous drinking episode events were included in the analysis since they were the events which were reported to be major reasons for treat- ment with sufficient variability to allow for logistic analysis. Results of the regression for the criminal offense event were not reported, as none of the coefficients were significant. No

Tab

le I

II.

Log

istic

re

gres

sion

co

effi

cien

ts

( f

S.E

.) a

nd o

dds

ratio

fo

r so

cio-

dem

ogra

phic

an

d dr

unke

nnes

s va

riab

les

on m

ajor

re

ason

fo

r tr

eatm

ent

(not

maj

or

reas

on

= 0

. maj

or r

easo

n =

11,

by e

vent

ty

pe.

Seri

ous

fam

ily p

robl

em

Hea

lth

Coe

ff.

+ S

.E.

odds

rat

io

Coe

ff.

f S.

E.

odds

rat

io

Wor

k pr

oble

m

Rel

apse

Se

riou

s dr

inki

ng

epis

ode

Coe

ff.

+ S

.E.

odds

rat

io

Coe

ff.

5 S.

E.

odds

rat

io

Coe

ff

f SE

. od

ds r

atio

Mal

e U

nder

ag

e 35

W

hite

M

arri

ed/li

ving

w

ith s

omeo

ne

Em

ploy

ed

full-

time

Inco

me

less

th

an

10,0

00

Edu

catio

n le

ss

- 1.

44 *

1.

10

0.06

0.

54 f

0.

25*

2.93

0.

50 +

0.4

2 2.

74

- 0.

43 +

0.2

2*

0.42

-0

.41

f 0.

23

0.44

-2

.28

* l.l

l*

0.01

0.

16 f

0.

21

1.39

-0

.99

f 0.

33**

0.

14

-0.4

0 *

0.17

* 0.

45

-0.3

4 f

0.17

* 0.

51

-0.6

3 +

0.6

9 0.

28

0.19

f

0.23

1.

45

-0.8

6 +

0.4

4*

0.18

-0

.34

* 0.

19

0.51

-

0.21

f

0.20

0.

65

-0.9

4 f

0.69

0.

15

0.36

f

0.31

0.

49

0.34

+ 0

.37

1.96

-0

.28

+ 0

.20

0.57

-

0.07

f

0.23

0.

87

0.00

+ 0.

69

1.00

-0

.73

f 0.

33*

0.23

0.

42 f

0.

38

2.32

-0

.31

f 0.

21

0.54

-

0.31

f

0.23

0.

53

-0.8

8 +

0.7

5 0.

17

0.09

f

0.25

0.

84

0.40

*

0.36

2.

22

- 0.

23 k

0.

20

0.63

-0

.06

+ 0

.20

1.13

0.63

+ 0

.87

3.50

-0

.06

f 0.

23

0.89

-

0.02

f

0.36

0.

97

0.14

f

0.21

1.

32

0.19

f

0.21

1.

46

than

hig

h sc

hool

D

runk

enne

ss

-3.0

7 2

1.65

0.

00

-0.5

0 f

0.25

* 0.

37

-0.5

6 f

0.55

0.

33

0.09

f

0.18

1.

20

0.23

f

0.22

1.

57

near

ly

ever

yday

D

runk

enne

ss

x

1.65

?

0.74

* 27

.10

mar

ried

*P <

0.0

5. d

.f.

=

1.

**P < 0

.01.

d.f.

=

1.

100

significant demographic by frequency of drun- kenness interactions were found for any of the events with the exception of drunkenness by marital status (married1 for the serious family problem event. Thus, Table III presents logistic regressions without the interaction terms, except for the family problem event.

There were large differences across events in regard to which variables were significant in the reporting of the event as a major reason for treatment. Gender was associated with a health confrontation and relapse being reported a major reason for treatment. Male clients were almost three times as likely to report a health confrontation event and more than twice as likely to report a relapse as a major reason when they occurred than females. Age was sig- nificant for serious family problems, work, relapse and serious drinking episode events. Those over age 35 were about twice as likely to report relapse and serious drinking episode events and seven times more likely to report work problems as major reasons for treatment when they occurred than those less than 35 years old. Ethnicity was significant only for the work event. Minority clients were five times more likely to report a work confrontation when it occurred as a major reason than Whites. Marital status was not significant for any event. However, it was significant in inter- action with drunkenness nearly every day for the serious family problem event. Employment was significant only for the health event. Those not fully employed were four times more likely to report a health confrontation as a major rea- son for treatment when it occurred than those fully employed. Income and education were not significant variables for any of the events. The drinking variable, frequency of drunkenness, was significant only for the health confronta- tion event. Those who got drunk less often than nearly everyday were more than three times likely to report a health confrontation as a major reason for treatment when it occurred than those who got drunk that often.

Discussion

Many individuals have a history of alcohol

use and concomitant problems. In the course of their drinking careers some handle their prob- lems without professional help; others enter treatment. The selection process is complex and still poorly understood - it is determined by a number of situational and cultural factors, both individually and socially defined. The problems which individuals experience in rela- tion to their drinking often play a role in the process by which people reach the clinic door. Studying these problematic events can illuminate understanding of the intersection of cultural, personal and social control processes that lead individuals to treatment.

The findings from this paper provide new insights about the relationship between alco- hol-related problematic events and treatment. First, for most events, there was variability in whether they were reported in either a cate- gory of being a major reason for treatment or that of not being a major reason when they occurred. In addition, the events that had a sig- nificant proportion of individuals reporting them as a major reason did not as a group stem entirely from a social policy framework or from an individual-level response. For example, while drinking driving showed a pattern of often being reported as a major reason for treatment, relapse and serious drinking epi- sode events were also major reasons for treat- ment a significant number of times when they occurred. These latter events would not have such a strong social policy connection.

Public drunkenness had a significant propor- tion of individuals reporting it not to be a major reason when it occurred. This finding points to a large shift in policy from earlier years when the decriminalization of public drunkenness was one of the reasons for the establishment of the present alcohol treatment system [14]. Acci- dents other than traffic ones also were not likely to be reported as major reasons when they occurred. These events also represent a mix of ones in which individuals come in contact with community institutions or do not.

Second, the characteristics of those experi- encing an event were not the same as those which predicted that the event would be reported a major reason for treatment. For

example, while gender did not vary greatly across events in regard to who experienced them, being female was associated with assess- ing relapse events as major reasons for treat- ment when those events occurred. These results are not surprising in terms of the litera- ture comparing the characteristics of women and men in treatment. Dahlgren and Myrhed [15] found that women often had problems which were more severe and acute than men. Beckman’s [16] and Lindbeck’s [17] reviews found that overall women’s problems were concealed and families often delayed treat- ment. In line with these findings, relapses may be events representing long-term problems that are beginning to show serious conse- quences, or the family defining another failure at self-treatment. Being over age thirty-five was also associated with four of the events reported as being major reasons for treatment, which could also indicate a longer history of problems.

Overall, these findings are consistent with the notion that social policy directed toward bringing new populations to treatment is often not consistent with epidemiologic information [18]. For example, drinking driving events dif- fered quite dramatically from other events in regard to the frequency of drunkenness every day of individuals reporting it. Other reports from this study have found significant differ- ences between respondents reporting a drink- ing driving event and those reporting other events regarding drinking problems, attitudes toward drinking and self-conceptions of alcohol problem status [8].

Finally, there were large differences across events regarding which variables predicted the reporting of the event as a major reason for entering treatment. Age was the only variable which was almost consistently a significant predictor of an event being reported a major reason for entering treatment. There were no other variables which were significant for more than one type of event.

Thus, in developing prevention efforts and early casefinding strategies we cannot general- ize which types of problems may be the “cue” which individuals decide is important in enter-

101

ing treatment or from one type of alcohol prob- lem to another which groups of individuals to target as most receptive to treatment. Studying the different types of alcohol prob- lems individuals experience and their respon- ses to them may shed new light on the process of entering treatment.

Acknowledgements

Preparation of this paper was supported by a National Alcohol Research Center grant (AA 055951 from the National Insitute on Alcohol Abuse and Alcoholism to the Alcohol Research Group, Medical Research Institute of San Fran- cisco.

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