Prhmenpies eG. | Practieds | ol Seid Healt | | Volume Three | i iu i sy , q iEee Alcohol on the College Campus W. Davip Burns A white male physician working in college health described the following encounter with a patient: ‘A 20-year-old, Christan, American-born white male came to the clini one Friday ‘morning with wo injured hands—both were badly bruised and swollen, In response to the questions "What happened?” and "How did your hands gec this way?” the student somewhat sheepishly reported chat he had gotten "mad and punched «wall ‘ducing a card game.” The clinician asked iPhe had punched ie with boch hands. The student replied “no,” he had hit he wall fist with one i and then lace, when he was angry abour something else, he ad punched i wth his athe fist. The clinician then {nguited, “Wereyou drinking?” The student responded, again somewhat sheepishly. “Yes” Then the physician reported eling/asking the patent, “That wasn't very smart, was i!” Again, che studene nodded in agreement. ‘The clinician then described the advice he gave to his patient for getting some telief from the pain in his hands, The clinician cid not follove up on che drinking part ofthis incident by taking 4 more deuailed history, inquiring about prior injuries or incidents, or eliciting sense from the patient as to how he felt or thought about the incident. The clinician reported feeling pressed for time ~ there were other patients waiting. More significant, however, is how the clinician appraised the seriousness of the incident. He reported that he did not rally think that patient needed any further investiga- tion or intervention. Afterall, he said that what the patient reported “wasn't that | unusual." The clinician described having seen alot of injuries of this same general __stiology, which is exactly why he thought ro ask che patient, “Were you drinking?” SKILLS AND Norms ‘This story illustrates, for those practicing in college health, what we now are coming to know about prevention, in general. We used to think that, in order to 58910 Volume Three: College Health prevent disease or achieve a desired health outcome, we needed to concentrate Oa Pijucation about the disease, its causes and what prevents it from happening or Jeceens its subsequent effect on the patient. Yet, we all know examples of students who know that drinking alcohol, in ‘ies that they would consider. 3 moderate, impairs judgment, Nevertheless, r jmpairmenc and claim that they will still know “when ro say wher.” Knowledge dove noc necessarily, or even often, translate into some direct action: In the words ‘of Richard Keeling, "We often do not do what we know.” In the place of knowledge, by itself, we are coming to believe that what affect alcohol use ~ and, by extension, what will improve the capacity of those in Student health who are charged with dealing with ic ~ boils down to two things: improving skills and having a clear idea about social norms, 4 To illustrate this point, let's return to che story that begins this essay. At firs the report reveals less than optimal history-taking — one of the most skills a clinician needs. While it was good that the clinician thought to tuk about alcohol, the value of the inquiry was diminished when the clinician ‘csentally told his patienethat what he did “wasn’t very smart.” In doing so, hewas, ‘ofcourse, judging the behavior, and he was expressing his sense of a norm, But, ‘hot really finding out what happened or why, the clinician missed a chance patient to injure ‘exchange another “norm”: d is opposed to something resembling a fa Conumed, no matterhowsmartyou are, youcan wind up gettinghurt.) By thist ih the encounter, the student was already on the defensive and, now, to escape fro the accusation that he had not been very smart, the student would have had Embrace the embarrassing position of arguing that punching the wall was evidence Of his own good judgment. To another observer, it sms entirely possible that punching a wall, as opposed to punching a person, was the smart (ot at least, preferable) thing to do, ifyou had to punch someching. That judgment, though, also beside the point. In his example, the presence of alcohol serves to explain, and ironically als co explain away, the behavior (after all, you wouldn't hita wall if you were sober). In « aaiseed way, ic becomes “normal” fora drunk person to do something that is not “very smart” The clinician described this drinking (and his estimation that the” student was drunk) as certainly not unusual but somehow “normal” — stupid, but normal. Given his sense of how normal che behavior was and the press of other business, the encounter ended and the contributing behavior and perhaps, even, the underlying problem that led to the behavior and the injury ~ excessive drinking —went unexamined and untreated. The student got help for his hands, but no attention was paid to his drinking. What was left of chis encounter in the records of the clinie would probably have been a “contusion,” or “hand trauma,” or accidental injury.” Alcohol, the not-so-silent partner in this event, most likely did not show up on the record of that clinician's day's work. A chance to make a difference in the student's life was lost. The best practice should lead in a different direction: The presence of alcohol should serve as a point of departure for further investigation. ‘ALCOHOL ON Campus Alcohol, as the common expression has it, is a drug. Indeed, on college campuses, itis the drug of choice. Alcohol is marketed to college students as a “specific” remedy for a range of conditions college students commonly report having; loneliness, fear of rejection, desire to be popular, stress, impostor anxiety, worries about the future, concern about appearance, sexiness, depression, over- work, and being under-appreciated. The manufacturers’ claims about alcohol’s ‘magical properties ~ and indeed, the testimony from some of its most ardent wsers = tells us thatalcohol helps you make friends, icincreases your chances of having sex, itmakes you more attractive, itloosens you up, itrewards you for the hard work that you do that no one seems to care about, gives you a sense of security, it makes you feel no pain, ic tastes great, and it gives you an excuse for doing something that you might not have had the courage to do if you did not have the help chat the drug provides, As a drug, it is relatively pure, is commonly available (without a prescription), can be purchased cheaply, has relatively predictable and short-term effects, and, since it is self administered (at least some of the time) it can be dose- adjusted to fit a particular need (or, when itis administered ro others, 0 achieve a desired result). Even though iisillegal for underage students to purchase it, alcohol iscommonly available and most parents would rather thatitbe used than any othet drug around. From a health perspective, alcohol use to the point of impairing judgment ot producing intoxication is probably the single most important factor in the undoing of several critical health practices that lead to significant tisks of morbidity and mortality. You will find alcohol at the intersection of virtually every collision between prevention and risk-taking behavior from seat belt use to condom use Alcohol use, because of its prevalence on college campuses, demands the attention, of anyone who seeks to have an impact on reducing 2 whole range of common conditions thatlead us co practice college health. Failure co pay attention to alcohol use on college campuses will undermine most of the outcomes desired from the practice of college health592 Volume Three: College Health INCIDENCE AND PREVALENCE ‘Alcohol use and abuse on college campuses has been described in many studies Itisestimated that some 90 percent of college students drinkat one time or another, and that a very substantial proportion ~ probably much more than half of white tnale college students — drink to the point of potential intoxication at least once Chery other week, (Fleavy drinkingin most studies is defined as five or more rinks onany one occasion. For many college students, this “standard! of heavy drinking srould noteven qualifyas their notion of moderate drinking, which isjustone more _ Mlustration of the problem with “norms.”) A good deal of drinking in college is heavy drinking in party settings, with drinking to {intoxication asan expected norm. of behavior, While a significant proportion of college students essentially abstain from drinking, about four times as many college students would qualify as heavy dunkers, as compared to the population ac large and its drinking pavterns. Even though the weekend drinking, which now seems to begin on Thursday nights” ‘Teodbes “campus culture,” good deal of the drinking by college students resembles the binge drinking of adult alcoholics. 3 ofalcohol is suficient vo suggest tha there are ewo major risks to college students, their fiends and those with whom they come into contact: ‘ 41. Acute risks - these embrace asec of immediate consequences thar come with ‘resale from aleohol consumption to the point of impairment or intoxica- tion, includingaleohol poisoning, accidents, injures, unwanted pregnancies, ‘sexually transmitced diseases, regretted sex, acquaintance rape, embarrass- nent, missed obligations, damaged reputation, disciplinary or legal conse~ (quences, anda range of injuries to others; and, ‘Chronic tisks-theseembracea setoflong-term consequences that come from persistentand continuing use of alcohol at quantities that result in damage co the vital organs of the body and produce patterns ofbehavior that damage the rinker’s capacity o sustain relationships, obligations ro work and commu nigy, and lead to premature morality. These risks are commonly described in ‘connection with addiction. “This distinction, between acute risks and chronic risks, is helpful toa point, But ican interfere with the effective practice of college health if the clinician remai Seack in thinking that alcoholism is the chief risk of drinking, Alcoholic drink and heavy drinking carry the sume short-term, acute risks. It probably matters ve le co the vietim that she was sexually assaulted by someone who was drunk for Th that wo patient: Fol ofthe Aies. aite nce nks ‘ing wore. eis ain avy. shts, ents tion Chapter 9. Burns: Alcohol on the College Campus _593 the firs time or by someone who had been drinking alcoholically fora long time. ‘Thiswill matter, however, in the treatmentand disposition of individual cases, once 2 good history is taken. PRINCIPLES AND PRACTICES: ‘Wuar SHoutp WE Br Dornc? The first principle applying to college health and alcohol is the same principle that would seem to be applicable to all that we do: We need to be engaged with our patients and help them with their lives. How can this be done? Following a public health model, the Task Force on Alcohol and Other Drugs of the American College Health Association has suggested a series of practices that apply to acute and chronic risks at primary, secondary, and tertiary levels of prevention.’ These standards emphasize, among other things, learning about the incidence and prevalence of alcohol use among your students, developing good skills at history taking and referral, intervening to adjust the environment that influences drinking, and making inquiries about alcohol use a relatively routine dimension of general care. ‘Theclinical managementof students with alcohol problems or problems related to alcohol is an area t00 large to cover in ths brief essay. Fortunately, Jean Kinney and Phillip Meiiman have given a very good, comprehensive introduction to alcohol issues within the college health clinical setting in their article, Alcohol Use and Alcohol Problems: Clinical Approaches for the College Health Service? The article containsan ‘excellent series of references for further reading that will help clinicians who want to increase their skills and capacity. Among other things, Kinney and Meilman describe a variety of sereening methods to use in history taking (including CAGE, Brief MAST, and the Trauma Scale; theater, fused in conjunction withadditional questions, would have helped the clinical encounter described in the opening story.) In brief, trauma secondary to drinking is a significant indicator of an alcohol problem that should have merited additional inquiry. Given the widespread use of alcohol at levels hat impair judgmentor have toxic cffects, it seems fair to recommend that virtually all clinical encounters in a college health service should include some questions about alcohol use, not just use by the patient but of those whose lives touch the patient in significant ways (e.g, sexual partners, parents, siblings, roommates, and so forth). Once this information is known, itis important to havea plan to evaluate what it means. This evaluation will fequire several things.594 Volume Three: College Health To be effective, the clinician will need ro: 1 Develop a learsense of what is “normal” and what needs further attention and intervention, What may have kept the clinician in our story from going any further in his encounter wich out patiene was the clinicians sense chat nothing as really ut ofthe ordinary inthe piceue presented by the patient Th fact, the clinician might have engaged in similar behavior when he was 2 college seadent (hence the poincof noting the genderand race oftheclinician, slong with the other obvious similarity: both had college experience) The sense of what is“wihin normal range” will vary from clinician co clinician. |f you concentrate on the outcomes you desire from your encounter withthe patient hen heavy drinking that impairs adgrnene wl merit your increased Frrention because it incrferes with so many of the other goals you may have for your patient. For example, if you want your patient to do well academi- cally, blackouts and binge drinking won't help achieve chat goal. [Fyou want to help your patient practice safer sex, then you need to know that drinking interferes with condom use. ‘You can begin to understand norms for your campus by asking students what they think heavy drinking or dangerous drinkingis. You can also look at the vast literature on college drinking that will give you a sense of what is happening on the campuses where drinking has been studied. How different do you think your campus i, and why? You will also need ro pay attencion to differences in gender and culture, and to those at some special risk: members of organizations chat have exaggerated drinking norms (like many fraternities and some athletic teams) children of aleoholics: and gay, lesbian, and bisexual students, Listen carefully tothe patient, ask questions and do not hesitate togive your patient your evaluation of his/her drinking behavior. Our clinician was not “Exhibiting good listening skis. He didn'c ask many questions, and he didn't hesitate to give his judgment, but he failed co give an evaluation of whar was happening, Tc would have helped if he had followed this advice. In spice of ‘what we know and will ater say about denial, students do seem willing ro rll: about their behavior. They may be wondering justas youare iftheir behavior is"normal.” This interest in some external measure, “Am Lall right,” is wha din the CAGE question: “Have you ever been concemed about your drinking?” Such discussion may make a positive difference in the patient's life. There is atleast one study that reports chat 29 percent of students suid “they changed. their drinking behavior" as a result of having a physician discuss the ‘consequences ofthat bchavior with chem, The unfortunate parcofhe study's resulsis that only 15 percencofstudents wereever asked about their drinking to begin with?johol on the College Campus _595 People seem to want to believe that what they are doing is pretty much what everybody else is doing, When they learn that their behavior is out of the attention otdinary~or not what they thinkeverybody elses doing —iccan change what from going they do. Promising work suggests hat students overestimate the amount of s sense that heavy drinking others do.** When they get the facts, they can be expected to the patient, bring their own behavior back away from the misperceived norm, The ain clinician's evaluation can help with cht proces. cae Getbeyondasocial/moralconstrucionofdinking to somethingthataccounts for ts risks and its potential toxicity. Excessive drinking seen as some necessary dimension of adolescent development is a particularly dangerous myth. And, despite what some would say, drinking is noe a sign of some moral defect ot shortcoming. It may not be smart, but lors of smart people do i. ‘odinician, rerwith the arincreased su may have umay Whacifour clinician had developed alee beter picture of his patient? Fhe had, he would have been berter able to predict future problems, and traccany Ifyou wane ites from past episodes ifherehad been any (nd there isa great iklibood atdrinking that there were) He would have been able to help the patient. ‘The degree to which we have such confused and ambivalent aetitudes abou dents what alcohol x remarkable. Ifa student came to the health center and reported nlookatthe drinking something poisonous at what could be toxic levels cis highly of wit i unlikely chat che appropriate treatment would be to advise “sleeping ic of" Yer, we do not often think oF alcohol intoxication as “poisoning,” We use a ay attention more value-laden name when we say someone is “drunk” ~ or “wrecked” or elle “crashed!” as the students say. The social constuction of incbriation prevents si nee us from engaging in optimal treatment. gay lesbian, Understand denialand earn how todeal withit. Wedonotknowenoughabout the encounter to tell just who may be in denial in our story: the patient, the togiveyour clinician, or both. Denial isa cough subject, but to understand ic we need to see can was oe how what we hope might be the case (that our patient is rally allright) might be ee Pee part of the patient's agenda as well (that he or she hopes we think everything is fine). Accomplished drinkers have accomplished skills at arranging thei lives to keep drinking from interfering with what they have to do (recall the weekend drinker, or the student who managesto schedule classes toavoid certain morning obligations). Sometimes there wil even be convincing external signs of success (good grades, athletic prowess, apparently successful relationships). In othee cases, highly elaborated defenses will resist penetration, The patient might genuinely believe tha everything is allright. Clinicians, to0, may be partof the denial—prefering o believe thacallis well 2. In spite of. ilingco talk reir behavior he," iswhat cerned about life, There is hey changed orthat wha chy ae seeing sjusta transient episode. Those responsible or cs as colleges and universities as institutions may also be disinclined to face the 2fehestudy’s consequences attending to a conclusion that their campus has an “alcohol reicdrinking e i ieee problem." The thoughts of parents and friends will often trace similar pateerns.596 Volume Three: College Health “To overcome denial, good hisrory taking is essential and these are several na ‘eetiniquesthatcan work, including makingan arangement with teseadent oR to get back co you if something thatthe student believes is an slated event pa te-oecurs. Agsin, confronting the student with your Findings and evaluations ei ine blpfal way may asi inthe student's coming co erms witha problem, On Ifyou can arange ie getting a patentinto a group can be helpful: Not only de wil che suadent come to see the possibilty thac there is help bur that others ith ate in similar circumstances. ea “i health service can assist in dealing with institutional denial by providing ind nonyimousinformation gleaned from clinical encounterstocampus officials the along with ther surveillance data obtained from systematic survey rscarch off rgeneralizableanecdotal information. Vera Johnson scssicbook, Iii Quit M: “Tomorrow, should help any clinician come to understand denialin away that ist will help clinically ber 5. Coordinate what you do with health education and health promotion tol Gflons and help the patient make the connection beoween drinking and cd ther outcomes desired by the student. Alcohol use on che college campus ia isa culeural phenomenon; that is, much energy has been ‘expended connect- Th ing drinking with being a college student. Successful interventions will th: require a culturalfenvironmental dimension as wel. = “Theclinician in our story was able to disconnect drinking from his ereatment Tare of the patient. He never reached for an educational opporcunity, nor did he au explore the context ofthe drinking. ae ‘A student health program should have 2 health promotion dimension that a inphasies, in adivon to knowledge about aleohol, skills needed to reduce iit “isle and harm, These include skills to avoid peer pressure (to increase « re etance and resiliency, skills in negodition and conflict resolution, and w ‘Tals st impeoving one’s sense of self. Linking to these programs offers © Tinicians the opportunity 10 magoify the effects of their encounter with t patents and connect patent to some ofthe larger isusin life, OF cours, e er the alcoholic student, 2 course in assertiveness taining may just make for tess angry but more assercve drunk, Such students wil require referal ro more specialized treatment. 6. Know what resources (services, specialists, clinics, self-help groups) are nnilable to your patient and know how to make effective referrals. Good Tosu principlesand practices entailknowing whatsevices are valableon campus, nsideris pethe community, and beyond, and baving sufficient Familiarity and confi- ‘to success dence in those resources to make an effective seferral. “The most obvious source of free help is Alcoholics Anonymous. Ironically, unsde its membership AA seems shrouded in mystery; however, itis easy to ‘lear up chac mystery. Every clinician in college health should acend an openChapter 9. Butns: Alcohol on the College Campus 597 exal | ‘AA meeting, just ro get a sense of it. Colleges should invite AA to meet on lent : campus and clinicians should make arrangements for students in AA to sent sponsor other students in che program. Bruce Donovan has written a ions wonderful essay that de-codes AA for physicians.” em. 7 (On-campus resources need to beidentified, burcateshould be taken toinsure only | that these services are capable of seeing the alcohol use asa primary problem, hers a ificis. does liale good to get an alcoholic enrolled ina time-management program, where referal ro someone for a more appropriate therapy is ding indicated. In the event chat a patient needs intensive, in-patient treatment, eae the optimal service will include a referal to program of high quality with arch effective arrangement for aftercare. Sait Making successful referrals isan arcin itself. Parcof what makes ceferal work ie 4 is the relationship becween the clinician and the patient and the match ob berween the patient and provider to which he or she is eferzed. Ieis helpful . tobeablerolerapatiencknow that youknow the quality ofthe person or place an that you think will help chem, and your authority — and chances for success and = will be enhanced ifyou can vouch for the quality of your suggestion. ppas Itisimportantto know that to havea program of high quality does notrequire al that all services be offered by your health service. To have quality, you need to know how to identify problems, gain the confidence of your patient, and make a successful referral. ment ”. Feel confident that you can help the student to make a difference in his/her life. Your work matters. Again, this last piece of advice has a general applicabiliy. If you know what is happening with patients and have the ability co enter the patient's world, you can and will make a difference in the life of your patient. Your confidence ~ and the ease with which you handle complicated problems and topics—will help your patient gecbetcer. Effective work with alcohol, as with other topics, can start with a searching self- examination ("How do I feel and what do I think about drinking). Tecan then be enhanced by reading and research, Ie will be informed by the clinical experience you gain in trying to make a difference. Lastly, chere are people to whom you can turn for help Wuat Is Keerinc THINGS FROM GETTING BETTER? s) are Good | Tosumup thisbrief discussion of alcoholasan issue in collegehealth, itis worth mpus, considering why more is not being done, and to identify some of the impediments confr Fro success and what can be done about them. Here area few things to think about, ically, ‘Time, TALENT, AND THE TERROR OF THE “YES” ANSWER yoren Pressed fortimeand lacking the confidence and capacity to handle the possible range of answers that a question might elicit, clinicians might exhibit what can be598 Volume Three: College Health called “the terror ofthe ‘yes’ answer.” It makes one’s job harder to go beyond the obvious ~ the bruised hands, in our example — coa line of questions that will ake. time and to answers to them that will equire engagement with che patient. Ifyou have just asked a patient about incest, and you learn that her father did try to have sex with her once, your next question can not be, “How do you think the weather be tomorrow?” or “Who's going to win the Super Bow! this year?” Your natural inclination might be t© avoid the subject altogether. This may seem like an efficiency consideration. Afterall, chere are patients waiting co see you. 4 ‘The answer is not simple, but it is obvjous. If you are committed to making a difference in the lives of your patients ~and in the quality fife on the campus and beyond — you will have to develop the skills to ask the question and deal with the. answer. And you will need to schedule another appointment with the patient, or juggle your next patient, to make the time to do ic right. This “terror” is real, however, and may be related to other factors that will be discussed here. What we find is that such a terrors present, expecially in those who know how to ask the questions, because they are the ones who are most likely and. most inclined to get themselves into a situation where once receiving the “yes” answer, they then feel and take on an obligation co do something about what answer means. ALcouoL Apust Is Just 4 TRANSIENT PROBLEM ‘Har Srupents Neep to Live TaroucH Another major impediments the belief that alcohol use and abuse is essential a transient problem, with a cure thae consists of living long enough co gee chro the risky period of adolescence. This belief comes from some relatively well supported evidence, which suggests that the abusive drinking going on in college does not lead, in most eases, to chronicalcoholism. But, of course che defect in th thinking is chat it connects drinking to only one kind of problem, namely the chronic problem of alcohol abuse or addiction. Ie is a mistake co use a statistical determinant, such.as the low probability of someone's drinking becoming alcoholic ornon-alcoholic, asa reason to refrain from intervention. Afterall, itisan individual whois being teated. But the larger mistake in this thinkingis thac somehow thee: of the clinician is to simply help the student live through this period of Sturm w Drang 0 emerge later as some adult who will not have the stress, or situational, age-determined excessive drinking that seems to be the ease in college. The most significant threats of acute injury, or infliction of injury to one’s self or others, the reason why one cannot reasonably take the position that the unikelihood af alcoholism is a reason for refraining from intervention today. There are too man risks to take chat chance. : Tue P Ad student fiercely - essentia interven, otherth call on ‘The Wealso andavoi “medicavond the will take «. Ifyou to have weather natural like an making a apusand, with the utient, ot acwill be nose who sentially through rely well- in college ‘ec in this amely the scatistical saleoholic ‘ndividual weherask, Staerm und ational, of | The most others, are hood of too many Chapter 9._ Burns: Alcohol on the College Campus 599 THE PROBLEM Is INTRACTABLE A third impediment co better care is the belief that alcohol use among college students is so entrenched that itis essentially an intractable issue, No matter how fiercely one is devoted to solving the problem, it will make no difference. This is «essentially an argument that sees abuse as inevitableand not amenable to any special intervention or change. There isa certain power to this argument because, among other things, itallows one to preserve the status quo. And in so doing, it reduces the call on any one of us to be actively engaged. The problem with this argument is that iis false — and dangerous. We know that treatment for students can work and thatearly intervention makes a difference. We also know that our missions cause us to take an interest in preventable disease and avoidable problems that lead to loss ofacademic productivity. Most important, wwe would never say the same thing about something that we considered more “medical.” Here we return to the problem of an exaggerated norm as a cover for a Jack of confidence in our skills. ‘That the problem is large and scems, therefore, intractable suggests the priority and vigor with which it should be pursued. 1 Don’t Want To Laset SoMEONE “ALCOHOLIC,” AND No One Cares Asout Wuar I Do, Anyway It's crue that we tend to value what we measure and we do not measure much aboutalcohol, clinically speaking, Wesee effects, not causes or contributing factors, and our accountability reports force us into choices that might hurt the patient. Clinicians are reluctant to apply labels that have potentially long-term and serious consequences, ifthey are unsure about the correctness of the diagnosis. Buc, to pursue a student’s alcohol problem does not require determining that he or she is alcoholic, no more than getting a mammogram on a breast lump means that a ‘woman has cancer. We need to be careful about tossing labels around, but we can pursue a clinical inquiry without making these mistakes and we can protect the patient from harm, All this can be accomplished in a clinical context that is supportive of serious work and interested in broad definable outcomes related co patient care. Such a service would be one most likely to provide support for the stafF development required to assure a maximal level of staff capacity and an accountability system that took cognizance of the importance of dealing with subtle, difficult problems. It would be a practice that measured the right things.600 Volume ‘Three: College Health, CONCLUSION “The clinician who saw the pasien with the bruised hands was avery Gee doctat Hie had the courage tall about his praccie anda willingness lean, He poe ejopatement hat was inerested in resltsand committed to develop ng tec He worked ata university that wanted do somethingabour is aleohe problem. Thisdoctor cared deeply about what happened co is patientsand wanted problem. [ifeencein ter lives, Hleknewall the reasons why he couldn’ edo bee testis commitment ro his practice and his patients cold him ‘what was wrong with ae corn knew that he, at his election, ook time for things that inceeed his exons ghotherewerewniting Helewhehad made adifferecein he! Of patients who had “impossible problems. (He had prevented sui Sxamaple’) Now, he eurns his attention to another issue = cere in his medial wining~ and armed with new knowledge, sew skills and animaced by his commitment to his patients ren cntsare getting beter, Heand otherslikehimareworking—¥el between risk-taking and prevention. American College Health Asociaton: Recommended Sanda Alesholand Other a oe Dependency ACH, Tsk Force on Alcohol and Ose Drs Jani 1988 Kinney Melman P:Aleoholsandalebol problems: Clin apprcaches fortes c Ihealth service, J Am Coll Health 36:73-82, 1987 - Hickenborom JP, Bisonewe RP, O'Shea RM: Preventive medicine and colle abuse.) Am Coll Health 36:67-72, 1987 Perkins HIW, Berkowitz AD: Perceiving the community norms of alechol uss arte ee pe severe implications for empus alcool education programming ‘Addict 21:961-976, 1986 5. Hines Me Diinkingon emput: Notas mucha you'd think Poco Today AV 6, Johnson VE: Tl Quit Tomorrow. New Yorks Harper 8 Rows 1980 47, Donovan Bs Wha he practicing physician neds to know abou shlp for chem dependents. Rhode Island Med J 72:445-489, 1989a very good tolearn, He odeveloping utitsalcohol sand wanted niedoberter, swrong with ax interested ceinthelives suicide, for | ived scant quipped with agbewer and thecollision = and OtherDrug « Drugs, January vesforthecollege | 4 college aleohol cohol use among gramming. Int] Today, Aug 1989 velp For chemical Chapter 9. Burns: Alcohol on the College Campus 601 Recommended Reading Johnston LD etal: Drug Use, Drinking, and Smoking: National Survey Results from High School, College, and Young Adults Populations. National Insticute on Drug Abuse, 1989) Kinney J: Clinical Manual of Substance Abuse. St. Louis, Mosby-Yearbook Ine, 1991