Sunday, April 08, 2007
The Prevention Paradox
Last week Vice Squad touched upon the idea that the majority of harms from an activity (alcohol consumption, in the case previously discussed) might be tied, not to a relatively small number of dedicated participants in the activity, but rather to chippers, low or moderate intensity participants whose overall prevalence might more than make up for their comparatively safe behavior. Among the observations that I failed to make is that this phenomenon has a name, the "Prevention Paradox," though precisely what is so paradoxical about it is hard to identify. Thanks to daksya for sending an e-mail to bring my attention to the discussion (a short editorial and four responses) of the Prevention Paradox in the February, 2006 edition of Addiction.
As the Finnish study reviewed in the prior post indicated, it isn't so much annual consumption but rather, episodes of binge drinking, that is related to overall harm. And as Ole-Jorgen Skog's editorial points out, this observation is consistent with the Prevention Paradox, if "most of the binge drinking is found among consumers with a moderate annual consumption level." Among Skog's conclusions is that regulatory "measures ought to be aimed at both drinking pattern (frequency of intoxication) and consumption level (intake per year), as well as drinking contexts."
Among the responses to the Skog editorial, one by Paul J. Gruenewald and Andrew Treno is quite stimulating. They note that we might be making a "category error" when we talk about moderate or heavy drinkers -- what we care about is drinking, not drinkers:
[T]he the notion of a 'problem drinker', like the 'reckless driver', brings with it an illusion of explanation, an explanation which, surprisingly, few seem to accept. Most researchers would agree that 'problem drinkers' are drinkers who have problems, but may not exhibit these problems the next time they are interviewed or surveyed. Does this mean that they are still 'problem drinkers' or not? On the other hand, the concept of 'problem drinking' brings with it other challenges which, surprisingly, also appear equally unacceptable. If all drinkers have problems sometimes, and some drinkers can be categorized as 'problem drinkers' sometimes but not others, how do we select cases to treat with our preventive interventions? Or is it possible that we should not select cases to study, but rather focus upon population interventions and outcomes, neglecting the individuals involved?As Gruenewald and Treno note, there is evidence that "most acute problems are related to moderate drinking (not 'moderate drinking groups')."
The inspiraton for this post leads me also to mention daksya's annotated summary of a drugs report prepared some years ago for the British Prime Minister.