case study examples alcohol abuse

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

• Open access
• Published: 14 April 2011

A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009

• Charli Eriksson 1 ,
• Susanna Geidne 1 ,
• Madelene Larsson 1 &
• Camilla Pettersson 1  

Substance Abuse Treatment, Prevention, and Policy volume  6 , Article number:  8 ( 2011 ) Cite this article

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Alcohol and drug prevention is high on the public health agenda in many countries. An increasing trend is the call for evidence-based practice. In Sweden in 2002 an innovative project portfolio including an integrated research and competence-building strategy for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This research strategy case study is based on this initiative.

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The data in the case study has been compiled using multiple methods - administrative data; interviews and questionnaires to project leaders; focus group discussions and seminars; direct and participatory observations, interviews, and documentation of implementation; consultations with the NBHW and the NGOs; and a literature review. Annual reports have been submitted each year and three bi-national conferences Reflections on preventions have been held.

A broad range of organisations have been included in the NBHW project portfolio. A minority of the project were run by Alcohol or drug organisations, while a majority has children or adolescents as target groups. In order to develop a trustful partnership between practitioners, national agencies and researchers a series of measures were developed and implemented: meeting with project leaders, project dialogues and consultations, competence strengthening, support to documentation, in-depth studies and national conferences. A common element was that the projects were program-driven and not research-driven interventions. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. The research strategy also includes elements of participatory research.

Conclusions

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organisations. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

Introduction

Alcohol and drug prevention is high on the public health agenda in most countries. The national initiatives differ, although action plans have been proposed by international organizations such as WHO [ 1 ]. Moreover, there is an increasing demand for evidence-based alcohol and drug prevention, causing an increased emphasis on research for prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. This means that prevention research needs to move "from basic to more and more applied research; from descriptive hypothesis-generating pilot studies to full-fledged, methodologically sophisticated, hypothesis-testing studies; from smaller to larger samples for testing; from greater to lesser control of experimental conditions; from more artificial 'laboratory' environments to real-world geographically defined communities; from testing the effects of single intervention strategies into more complex studies of multiple strategies integrated into intervention systems; and from research-driven outcome studies to 'demonstration' projects that evaluate the capacity of various types of communities to implement prevention programs based on prior evaluations" [[ 9 ], p 183]. It has also been more than 10 years since Nutbeam [ 10 , 11 ] noted the gap between the need for knowledge and the priorities among researchers.

Many years have passed since these recommendations, but still the gap between evidence and practice has not been bridged despite important achievements in implementation research [ 12 ], designs for effectiveness and translation research [ 13 ], and a series of initiatives regarding the evidence-practice gaps [ 14 – 22 ]. The call for more practice-based evidence is a challenge for policy-makers, practitioners, researchers, and funding agencies [ 17 , 23 ]. In several countries research on alcohol and drug issues has been incorporated into addiction research centres [ 24 – 28 ]. For many years much addiction research has been the product of specialized research centres rather than the contribution of standalone scientists. Moreover it is the specialist centres, in collaboration with the national funding agencies, which today assert leadership, set agendas, and help determine standards [ 24 ]. However, a common element in the missions of these centres is monitoring the substance use in the population, its causes, and courses, while prevention research is not high on the agendas. Furthermore, the establishment of national centres demonstrates the political administration's emphasis on scientific, evidence-based policies, but at the same time demonstrates the view that credible research is best performed within independent scientific bodies [ 26 ].

In Sweden in 2002 an innovative project portfolio for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This included an integrated research and competence-building strategy to strengthen alcohol and drug prevention. This case study aims to describe and analyse this initiative.

AD prevention in Sweden - legislation, national action plans, resources, and actors

Sweden has a long tradition of a restrictive alcohol policy [ 29 ]. The temperance movement became a powerful actor in the Swedish alcoholic beverage policy [ 30 ]. Moreover, Sweden is one of the few countries in Europe with a narcotics policy that aims to create a society entirely free of illicit drugs [ 31 ].

The overall goal of the Swedish action plan on alcohol and narcotics is to promote public health by reducing the medical and social harm caused by alcohol and to create a drug-free society. The strategy for achieving this goal with regard to alcohol is to reduce the total consumption and prevent harmful drinking, taking into account differences in living conditions among boys, girls, men, and women. Six priority sub-goals have been adopted: alcohol should not be consumed in transport contexts, at workplaces, or during pregnancy; children should grow up in an alcohol-free environment; the age of alcohol debut should be postponed; drinking to point of intoxication should be reduced; there should be more alcohol-free environments; and illicit alcohol should be eliminated. The sub-goals in the action plan on narcotics are to reduce recruitment to drug abuse, induce people with substance abuse problems to give up their abuse, and to reduce the supply of drugs. Interventions targeting children, adolescents, and parents are of high priority [ 32 ].

Swedish alcohol policy is based on a combination of taxed-based price controls and the alcohol retail monopoly in order to limit the availability and accessibility of alcohol [ 32 ]. There is strong evidence for the preventive effects of an alcohol retail monopoly [ 33 , 34 ] and high prices on alcohol are regarded as one of the most effective ways of reducing total alcohol consumption and alcohol-related problems [ 35 ]. When Sweden entered the EU in 1995, the conditions changed and Sweden could no longer have an independent alcohol policy. For example, the availability of alcohol increased as a result of changed rules for private import, and alcohol taxes had to be adjusted. The numbers of alcohol shops as well as their opening hours have also increased remarkably since 1995 [ 29 ]. The increased movements across borders have also had an influence on the illicit drugs market. Almost all narcotics that are consumed in Sweden have been produced outside the country. A well-developed international collaboration is therefore of high importance for the limitation of illicit drugs in Sweden [ 32 ].

An effective alcohol and drug policy also requires national coordination. The Swedish government has established a national council for alcohol, narcotics, doping, and tobacco. The council consists of members of public authorities, civil society, and researchers, and is led by the State Secretary of the Ministry of Health and Social Affairs. The council is commissioned to advise the government on issues about alcohol, drugs, doping, and tobacco and to present information about research results [ 36 ].

There is a need for the different sectors in society to increase and deepen their cooperation for an effective prevention of the use of alcohol, tobacco, and drugs. In the Swedish action plan on alcohol and illicit drugs as well as in the government bill for public health the importance of the voluntary sector is emphasized [ 36 , 37 ]. In the latter document, A renewed public health policy , it is stated that cooperation between the state and the voluntary sector should be expanded and that the conditions for the voluntary sector's work should improve [ 37 ]. An agreement about the relations between the government, the voluntary sector in the social setting, and the Swedish Association of Local Authorities and Regions has recently been developed through a dialogue between the parties. The dialogue is another way for the government to call attention to the voluntary sector and to its ambition to strengthen the sector and improve its conditions. The goal of the agreement was to strengthen the independence of the voluntary sector as moulders of public opinion and to support the development of public medical service carried out by the voluntary sector [ 38 ]. The Swedish voluntary sector has a long tradition of alcohol prevention, especially the temperance movements [ 39 ].

NGOs in Sweden

The Swedish voluntary sector is both different and similar to those in other countries. A major difference lies in its history in that, for instance, as early as in the 16th century the responsibility for health and care was organized under the state instead of in the regime of the church. In parts of Europe the church still is an active actor in health and care [ 40 , 41 ]. Also, popular mass movements have played an important role in the development of Swedish society [ 41 , 42 ]. The Swedish voluntary sector is as large as in other industrialized countries, although quite different in character. It is dominated by organizations in the cultural and recreational field, mainly sports organizations. Since the early 1990s the Swedish voluntary sector has expanded, particularly in the two areas of culture and recreation, as well as in the area of social care [ 43 ]. It can also be called membership-based; almost everyone in Sweden is a member of some organization. Because of these differences in history and structure in different societies, the voluntary sector plays different roles. In Sweden, NGOs are more of a complement then a substitute for state programs, and have an important role as forerunners and innovators [ 44 ].

Previous research has shown that the Swedish voluntary sector was highly dependent on public financing, which is partly correct. Looking at the entire sector together, about 30 percent of its financing comes from government funding. However, within the health care and social service sector, public financing stands for more than 70 percent. That is quite high in comparison with other European countries, but not the highest [ 45 ].

Support to NGOs today

Organizational grants.

The National Board of Health and Welfare (NBHW) has a government commission to administer the grants to national organizations for the disabled, the elderly, and relatives of elderly persons; to national organizations in the social setting; and to national and local organizations. For the moment this amounts to about 300 million SEK to about 100 organizations. Also the Swedish National Institute of Public Health has funds to distribute to NGOs or to other organizations working together with NGOs. The Swedish State Inheritance Fund is also a possible source of funding for NGOs. They administer over 300 million SEK a year to provide grants to NGOs working with children, youth, and the disabled. In addition other governmental agencies such as the Swedish National Board for Youth Affairs also support NGOs.

Project grants

In the late 1990s a new system of awarding grants to NGOs in the arenas of alcohol and narcotics, vulnerable children and their families, and violence against women was prepared. The previous systems were from the late 1970s and early 1980s, and during the 1990s many investigations recommended a better, more structured follow-up and evaluation of the NGOs' work. One new idea that emerged during the 1990s was increased performance management, that is, the need to point out achieved results and effects of different activities. It was emphasized that the government should not interfere with the running of the organizations but does have the duty to monitor the use of the grants. There was also a desire that renewal efforts and collaborations should be encouraged and supported.

In the late 20th century grants were awarded through the Swedish National Institute of Public Health (with money from the Swedish State Inheritance Fund) to a number of alcohol and drug prevention projects. A final report and an internal evaluation were required from the applicants. There was also an external evaluator, who conducted an evaluation of 11 projects focusing on their working processes [ 46 ]. Among the lessons learned from this evaluation were that the way of working should be characterized by frequent contacts and dialogue between the funding agency and the project, and also by supervision. The evaluation report also suggested that the support to the project leaders should be reviewed with regard to the possibility of different types of need-based support. Moreover, the short-term thinking in the funding of these kinds of projects was not in line with the needed time-frame.

Setting the Scene: NGO strategy for alcohol and drug prevention

Non-governmental organizations have received grants from the NBHW to conduct alcohol and drug preventive work in a special venture since 2003 [ 47 ]. This initiative is part of the national plan of action to prevent alcohol-related harm and the national plan of action against narcotics and comes from the Ministry of Health and Social Affairs. The working committee, which decides who will get funding, consists of members of the NBHW, the Swedish National Institute of Public Health, and the Swedish National Board for Youth Affairs (previously members of the Swedish Alcohol Committee and the Swedish National Drug Policy Coordinator were included). The working committee, after consulting the research team at Örebro University, also decides which projects will be studied in-depth. NBHW's initiative represented a new way of thinking. One point of departure was to create a project portfolio with a broad combination of organizations to mobilize many forces in the alcohol and drug preventive work. The initiative also contains supervision for the project leaders, competence support through regular meetings for project leaders, and an integrated Research & Development (R&D) investment (Figure 1 ).

Integrated research and development for NGO alcohol and drug prevention .

Need for knowledge building and learning

There is an increasing trend towards promoting evidence-based public health initiatives. International expert committees have presented the state of science with regard to alcohol prevention: Alcohol Control Policies in Public Health Perspectives [ 48 ]; Alcohol Policy and the Public Good [ 49 ]; and Alcohol: No Ordinary Commodity -Research and Public Policy [ 33 , 50 ]. National authorities have presented reviews presenting evidence for practitioners and politicians [ 51 – 53 ]. However, there are important knowledge gaps to be filled. Among these is the lack of effectiveness studies where the external validity is high. If we want to see more evidence-based practice we need more practice-based evidence [ 54 ]. This means an improved emphasis on cooperation between researchers and practitioners [ 10 ].

A comprehensive perspective on the concept of knowledge, including scientific and practical knowledge as well as practical wisdom, is needed. Scientific knowledge about alcohol and drug issues needs to be complemented with knowledge about methods for alcohol and drug prevention. As in other public health fields, ethical issues and practical wisdom are important [ 55 ]. Moreover, the science, craft, and art of implementation are of utmost importance. There are many reasons besides practicalities that are significant for the implementation of programs [ 7 , 56 ]. In a recent review, 23 different factors were found that were of importance for the degree of the implementation [ 12 ] and that also have a great impact on the program effects.

Research on alcohol and drugs has often been organized in special research institutes, which often focus on basic research on alcohol and drugs [ 24 – 28 ]. This basic research is related both to basic biomedicine as well as social and behavioural studies. Another activity, which has been accorded great prominence, is the monitoring of alcohol and drug use in the population in general as well in different groups. Intervention research has been given less prominence in these often national research institutes. However, the national agencies, such as the Swedish Institute of Public Health, have been involved in the evaluation of different intervention projects. So far research on NGO-driven alcohol and drug prevention has been almost completely lacking. Research has been a more or less exclusive activity for the university. However, this has been based on the trust in the impartiality and objectivity of the university-based researchers. The downside of this position is that this type of research may lack the necessary cultural awareness and insights necessary for a proper understanding of basic factors for successfully planning intervention programs as well as evaluating research efforts. In other words the roles of the researcher in intervention studies need to be addressed. In a recent study, Holmila et al. [ 57 ] outlined three different positions for researchers in community intervention studies. The researcher can be an external observer, not taking part in the preventive activities - acting as an unobtrusive observer . The researcher assumes no responsibility for the design or implementation of the projects but acts as an independent conductor of process evaluation and observer of project outcomes. Another position is to be a researcher-as-technical advisor . In this role the researcher has responsibility for evaluation but also takes the responsibility for providing scientific advice on effective preventive strategies if asked for [ 58 – 60 ]. This could include training and technical assistance to the projects. Progress reports on findings as well as results from different on-going studies can be presented to the practitioners, which may use this information as they desire. A third type is researcher-as-designer , where the project is designed by the research team in partnership with the practitioner. The researcher is an active participant in project planning as well as the process of carrying it out and evaluating the effects. This approach is particularly useful when the goal is to test one or more designed prevention strategies under as close to optimal conditions as possible. Examples of such in Sweden are the STAD Project in Stockholm [ 61 ] and the Trelleborg Project [ 62 ]. The Örebro Prevention Program is an example of a program where all parts of the process were in the hands of the researchers [ 63 ].

The present paper aims to describe and analyse alcohol and drug prevention supported by the NBHW and implemented by NGOs in Sweden during 2003-2009 with a special emphasis on research and development for an evidence-based practice. The case study analyses also the integrated research strategy and its main components.

Three research questions will be addressed:

Which types of organizations and projects have received grants from the NBHW for AD prevention?

What types of research and development activities for an evidence-based practice have been included?

How can a trustful partnership develop between practitioners, national agencies, and researchers?

Methods and materials, case study approach.

A case study method was chosen as the intention was to understand a real-life phenomenon in depth and the contextual factors were highly pertinent to the study [ 64 ]. This method investigates according to Yin contemporary phenomenon in depth and within its real-life context, especially when the boundary between the phenomenon and context are not clearly evident. Moreover, the case study approach copes with the situation such as in this case in which there will be more variables of interest than data, which leads to the need for multiple sources of evidence, with data needing to converge in a triangulating fashion. Furthermore, benefits from the prior development of theoretical propositions to guide data collection and analysis [ 64 ]. The present research strategy case study is on an organisational level. It studies a social process in a situation in which we have little knowledge of the phenomenon, integration of research in alcohol and drug prevention run by NGOs. Case studies as a main research strategy are selected as this is a unique case in Sweden, the impossibility to isolate the process and the intention is to combine research and action [ 65 ].

An embedded single-case design was chosen for the study. All the projects run by the NGOs are seen as embedded units of analysis in the study with special emphasis on the fourteen in-depth studies.

Participants

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The participants in this research strategy case study are the NGOs applying for funding to the NBHW and especially those NGOs that have received funding during 2003-2009. The project leaders and managers in the NGOs as well as the members of the different target groups are also participants in this study. Moreover, staff at the NBHW as well as other stakeholders is included.

Case study questions

When the research program started a set of overall research questions were developed. In this paper the focus is in one of these, how can a trustful partnership for practice-based research be developed? Additional questions concerns: the role as a project leader in NGOs, the impact of competence development, methods for documentation of project development, and the added value of running projects in NGOs.

Case study protocol

A plan for the research and development activities was developed the first year and amended each year after the completion of the annual report to the NBHW. This plan consisted of several parts relating to the overall activities as well as the different in-depth studies. Notes were taken at meetings and as part of the strategy a series of presentations as progress reports were given to, project leaders, NGOs and the NBHW.

Development of a Case Study Database

In the present study a broad range of methods was used in the data collection. This includes six types of data.

Administrative data

The applications from the NGOs to the NBHW as well as the funding decisions were the initial data, which was complemented by bi-annual as well as annual progress reports from all funded projects. These reports, which were submitted following a format developed by the research team, gave information on implementation and goal achievement as well as reflections on barriers and facilitating factors. The research team introduced this approach at a meeting with the project leaders, and this reporting resulted in an annual report to the NBHW on the progress of the alcohol and drug prevention projects run by the NGOs.

Interviews and questionnaires to project leaders

Data was collected from project leaders and their organizations in the years when funding was received from the NBHW. In 2003, 2005, 2007, and 2009 all project leaders were invited to respond to a questionnaire containing questions on being a project leader in a non-governmental organization. If the same project leaders were responsible for a project for more than one year they responded to more than one questionnaire. Most of those who answered the 2003 questionnaire also answered the 2005 questionnaire, due to the fact that many of those projects receiving funding in 2003 also were being funded in 2005. In total, 84 persons participated in the questionnaire study over the years. Of these, 38 project leaders answered the questions more than one year.

Focus group discussions and seminars

Thematic discussions were held as a part of the meetings with the project leaders. These highlighted special issues related to the practice of alcohol and drug prevention. Moreover, a series of joint seminars with NGOs and the research team have been held at national and organizational conferences focusing on different projects.

Direct observations, participatory observations, interviews, and documentation of implementation of the in-depth studies

The research team collected information by a variety of methods during the planning, implementation, and evaluation of the in-depth studies. Part of this data has been used in the analysis, resulting in separate reports and scientific publications. However, in this context more process-related data will be used to give insights into the development of the partnerships between researchers and practitioners.

Consultation with the NBHW and the NGOs

In the present paper information retrieved during the management of the NBHW support to the NGOs will be an additional source of information. Regular meetings have taken place with the steering committee and the senior administrative officer, who have been the same persons during all years. The consultations with the NGOs were more intense for those organizations selected for in-depth studies, but several meetings have also taken place with other organizations. Apart of the in-depth studies was feedback on preliminary results from different studies; this never radically changed the interpretation of results but did add valuable information.

Literature review

A systematic review of the research strategies for alcohol and drug prevention has been carried out as an integral part of the research program. A number of publications related to collaboration between researchers and practitioners were found. Special thematic sections and series have been looked for. Among the key words are addiction research centre, alcohol and drug research, preventive research, practice-based research, and evidence-practice gaps.

Analytical methods

The analytical approach in this case study follows a common strategy used in research programs: to start with the ordinary preventive activities and then study what is happening [ 66 , 67 ]. Using a naturalistic approach, which is always practice-based, it has been important to let different actors and stakeholders into the knowledge-building program. This also has implications for the selection of research and evaluation methods, given a need for mixed-method approaches [ 68 – 70 ]. In studies of effects, quantitative approaches are essential, but important contributions can be achieved if qualitative studies are also included [ 71 , 72 ]. The mixed-methods approaches have been developed for some of the more extensively studied programs, which also will be included in doctoral dissertations [ 73 , 74 ].

The analysis starts with a quantitative description of the investment in NGOs by agencies awarding grants and an analysis of which organizations and projects that were supported. The types of organizations are analysed with regard to their main focus or mission. Then the investment in research is described including an overview of the participants in different empirical studies using a range of data collection methods. This includes a description of how the embedded units, the project in the NBHW portfolio, have been documented and presented in annual reports using a format for the written reports based on questions and answers in the case study database [ 64 ]. The two types of in-depth studies are briefly presented: effect studies and studies of process and implementation.

An analysis of the experiences of cross-project comparisons as well as using the multiple sources of evidence in the case study database follows. The different measures in the research program was developed in order to foster a trustful partnership is then presented. These measures were assessed by all project leaders in the annuals reporting to the research team, which reviewed the content of the research strategy each year in the annual report to the NBHW. The implementation of the research strategy with regard to evaluation initiatives together with the NGOs as well as in-depth studies was carefully documented over the years and used as indicator for developing a research partnership with the NGOs. In this case study the focus is on the implementation of the research and evaluation efforts and not on the outcome of the alcohol and drug prevention program. This has been reported in other publications [ 47 ]. The different types of data and perspectives included in the case study database are used for triangulation and finding key elements and mechanisms in the research strategy. In this case study a mixed-methods approach means parallel mixed data analysis, i.e. parallel analysis of qualitative and quantitative data from different sources. Moreover, integrated mixed data analysis also occurs in the analysis of the project portfolio and subsequent development of research initiatives. To grasp the complexity and inclusiveness of integrated methods the term inference has been proposed as the last and most important stage of research [ 70 ]. The inference process consists of a dynamic journey from ideas to results in an effort to make sense of data. In our case study the regular project leader meetings as well as the preparation of the annual evaluation and reporting to the NBHW are key activities in this process of drawing inferences. Key concepts in an integrative framework are inference quality, which is related to design quality, interpretative rigour, and inference transferability.

The results will be presented according to the three research questions. The calls for applications resulted in many proposals from many different organizations for a variety of projects engaging many project leaders.

Investing in the NGOs - Allocation of Grants 2003-2009

Since 2003 10-15 million SEK per year have been administered to this special venture (Table 1 ). The government's decisions have over the years differed somewhat according to which target groups are being specially addressed in the calls for grant applications. For the first period, which was a two-year period, the call was broad. For the second period, 2005, the main part of the grants went to projects from the earlier period. From 2006 to 2009 the target groups have been children, youth, young adults, and the workplace according to the national action plans. It has also been emphasized that the projects would be new or in the process of expanding existing activities.

About one in four applications were awarded a grant. The amount of funds provided to NGOs varies. The minimum amount of funding for one year was 40,000 SEK and the largest amount was 1,200,000 SEK. Many organizations have been funded for several years. Over the years 2003-2009 the NBHW has in total apportioned about 80,000,000 SEK to the NGOs. In addition a yearly grant has been awarded to an integrated Research & Development (R&D) program as well as funds for administration and information activities. The total allocation from the NBHW has been 95,000,000 SEK, covering 135 projects in 69 organizations funded during these years.

The projects differed in size. Table 2 presents these 219 project grants over the years 2003-2009. The reason for this lower number of project (135) is that 50 projects have been funded over more than one year, 26 projects over two years, 17 projects over three years, and two projects over four and five years each. The first period, which covered two years, had the highest number of large projects. Moreover, the number of funded project has increased between 2005 and 2008 and the number of large projects has remained relatively stable since 2005.

Organizations and projects

The strategy to involve a broad range of organizations has been successful. In Figure 2 the 69 organizations and the 135 projects are presented according to type of organization. The largest number of projects were run by the nine alcohol and drug organizations. More than half of these projects were run by the Swedish temperance organisation IOGT-NTO (24 of 38 projects) amounting to 15 million SEK. The majority of these were small one-year projects, except for two programs where effect studies were conducted by the research team and the organization jointly. Between 15 and 20 projects were run by organizations focusing on social work, assistance, and ethnic groups. About 10 projects were run by sports, adult education, and religious organizations respectively. Furthermore, 14 projects were set up by two umbrella organizations each consisting of a number of member organizations.

Organizations and projects in different types of organizations according to main objectives .

The projects have different primary target groups for their activities. A majority of the projects have children or adolescents as target groups. Some of these projects are focused on young girls with the aim of promoting self confidence and a positive self image. Sports organizations have been developing alcohol and drug policies including anti-doping initiatives. Projects run by ethnic groups have as their target group members of their organizations including children, adolescents, and parents. A few projects have the workplace as the arena for intervention.

During the first years, three community-based projects were funded. These aimed to reduce drugs in two parts of Stockholm and the island Gotland. The strategy included a range of activities and collaboration with different actors. A broad membership in the organizations seems to be important for the sustainability of the community-based prevention.

Only one project has reduction of availability as its focus. This project focused on following up the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and the effect of different strategies to influence shops to comply with the law [ 74 ].

Internet has a great potential in promotion and preventive work [ 76 ]. The majority of the organizations have their own website on the Internet and about one third have a project-specific site. The organizations used information technology as a source of health information in three projects, as an intervention medium in four, for professional development in two, and as a research instrument in one project. The use of e-screening as a tool for drug prevention is studied by researchers at Karolinska Institute. There are still very few scientific evaluations of the use of Internet in drug prevention [ 77 ].

Basic characteristics of the project leaders in the alcohol and drug prevention projects are given in Table 3 . All four years the proportion of women was larger than men; about two of three project leaders were women. Most of the project leaders belonged to the age group 41-50 years in the early periods (2003/2005) while in the later periods (2007/2009) an increased proportion of the project leaders were 50 years or older. Moreover, nearly one in ten project leaders was 30 years or younger. Many of the project leaders in volunteer work were members of the organization before being appointed project leaders (Table 3 ). In 2003 eight of ten project leaders were members compared with four of ten in 2007 and 2009. Nearly half of the project leaders were also doing volunteer or non-paid work in the organization. No gender differences were found in the prevalence of non-paid work.

Investing in Research and Development

A research and evaluation strategy was developed by the research team at the School of Health and Medical Sciences, Örebro University. This strategy rests on collaboration with the NGOs through regular meetings with all project leaders, development of systematic documentation of project objectives, activities, and results, annual reports to the NBHW, and biannual national conferences Reflections on prevention (2006, 2008, and 2010). The role of the researchers can most closely be characterized as researchers as technical advisors . In some projects the researcher had the position of an unobtrusive observer -for instance in following up some projects in which no longitudinal data collection was included. In addition, in no project did the researcher have the position of researcher as designer . Moreover, separate competence development and discussion of evaluation studies were conducted with a smaller number of organizations. The steering committee at the NBHW also decided, after consulting the research team, on a number of in-depth studies. Fourteen such studies were included in the funding from the NBHW (Table 4 ). The research team was also involved in three additional studies funded by other sources. These studies focused on policy development in the Swedish Football Confederation, evaluation of regional collaboration against illegal alcohol, and alcohol prevention in Novgorod, Russia.

This set of studies included systematic collection of data from children, parents, and actors in projects. A description of the empirical studies carried out between autumn 2003 and spring 2009 is given in Table 5 . Different methods, including questionnaires, personal interviews, telephone interviews, and focus group interviews, have been used depending on the purpose of the study. The main research questions have been related to the process or effect evaluations of these projects. The majority of the studies have been carried out with adolescents, as many of the projects receiving grants from the NBHW are targeting adolescents for the purpose of preventing alcohol and tobacco use. In three studies, data have been collected from both adolescents and parents, and two of these are longitudinal studies with adolescents and their parents. Dyads of adolescents and parents are identified and have been followed over the three years of secondary school. All youth surveys have been carried out in a school environment while the questionnaires to the parents have been sent by mail. Municipalities, schools, and organizations across Sweden have participated in the studies. There are many advantages with the partnerships that have been developed between the research team and the project leaders within the NGOs. For example, the large scale of the studies that have been carried out during the six years could not been managed without this cooperation. The project leaders have done much of the practical work locally, such as the dialogue with participating schools and organizations, distribution of questionnaires, and sometimes also feedback to participants.

What types of research and development have been included?

All projects in the project portfolio had to submit semi-annual and annual reports. These reports were analysis and synthesized into an annual report to the NBHW. This was based on a reporting format using questions for different important elements in the projects as well as key aspects of project management. The preparation of the annual reports included cross-project comparisons with regard to the case study questions, which resulted in some amendments and changes over the years in the research and development activities.

After the decision on potential projects for in-depth studies, planning meetings were convened with the project leaders and managers in the NGOs. Based on the project proposals and joint planning between the project leaders and the researchers, a plan for the in-depth studies was developed. Depending on the evaluation and research questions and available resources the focus, design, process, and outcome measures were set (Table 6 ). The overall results were positive; ten of the fourteen in-depth studies were completed. One project did not succeed in recruiting high-risk parents to a parental support program (IOGT-NTO Centro). Three projects were only partially completed: one started before the research team was organized, making the evaluation impossible (IOGT-NTO: Dare/Young and King); one was cancelled after a decision by the municipality (SMART Västernorrland); and in one it was impossible to follow up information from policy-makers due to a low response rate (Makalösa föräldrar). Eleven of the in-depth studies started during the first period (Table 4 ). There were some common research questions such as the effects of the projects. The NGOs wanted their approach to be studied in such a way that, in the event of positive results, the program could be regarded as evidence-based.

Effect Studies

Seven projects were considered for evaluation with effect studies, which were planned for all seven projects. However, one project was unsuccessful and two only partially completed due to overly limited implementation. One project was already implemented when the research group was appointed. It was nevertheless possible to plan and successfully complete effect studies even with short-term yearly funding.

KSAN "About small things"

The aim of this project was to develop and test an early intervention targeting pregnant women to prevent alcohol injuries in unborn children. The project was developed by the KSAN, an umbrella organization for women's organizations concerned with alcohol and drug issues, and the Swedish Association of Midwives. It was implemented in a maternal health centre in Stockholm. A randomized controlled study was completed with 454 mothers randomly assigned to either receiving an information folder with the message "Pregnancy is not a time for risk-taking" sent to their home after the telephone contact for booking the first visit to the midwife, or getting the folder during their first visit to the midwife. The effects of the intervention were measured by a questionnaire that the pregnant women answered at the maternal health centre before they met with the midwife.

IOGT-NTO: Strong and Clear

Strong and Clear is a parental support program targeting parents with children aged 13-16 years. It is a universal program aiming to prevent drinking among adolescents and to maintain parents' restrictive attitudes concerning adolescents and alcohol. The program is manual based and includes thirteen activities during the three years of secondary school. The parents can sign up for the program during the whole period the program is carried out. There are both group and self-administered activities divided into four types: parent meetings, family dialogues, friend meetings, and family meetings. The program was implemented in six schools.

The research program includes the effect study, which was designed as a longitudinal quasi-experimental study, and studies of parental attitudes and behaviour with regard to adolescents and alcohol [ 78 ] as well as reasons for non-participation [ 73 ]. In the longitudinal study, 706 children and 613 parents participated in the baseline questionnaire, which was followed by repeated data collection in the two following school years.

IOGT-NTO: Parents Together

The program Parents Together consists of three parents' meetings during three years in secondary schools. The intention is to motivate the class parents to come to an agreement on the following issues: "We enforce the 18-year limit for alcohol; We will not provide each other's children alcohol; We will get in touch with each other if we see a child we know who is not sober, is behaving badly, or is out at times and places where we would not want our own children to be."This agreement is used to strengthen the cooperation among parents. The idea is that this will make a difference with respect to the children's alcohol use. A parent-teachers meeting is held each year to update the agreement.

The design of the study is a cluster randomized controlled study in Swedish secondary schools with seven intervention and six control school. The study included almost 2000 pupils and their parents. The program Parents Together was carried out over three years in the seven intervention schools with a start in both school years 7 and 8 (Figure 3 ). The six control schools have been offered the program for parents whose children are in year 7 in the spring 2009 and the program will follow in the years 2010 and 2011. To reveal effects of the program the evaluation also includes a questionnaire about the prevention work in schools and implementation reports. The non-governmental organization IOGT-NTO is responsible for the program and the implementation in the seven intervention schools. To maintain the cooperation between the thirteen schools, the NGO, and the research team, an agreement has been signed. The agreement includes information about the responsibilities of each party such as that the researchers should the results of surveys, within six months after the data collection, are published on the website.

Design of the intervention and evaluation of the program Parents Together .

IOGT-NTO Centro: Parental Support

This project was planned to include before and after questionnaires to high risk parents. However, the project did not succeed in attracting this type of parents to the program.

Hassela solidaritet: Peer Support in School

This NGO works with training and assisting school children to be peer supporters in their own school. The aims of the project are to prevent social exclusion by reducing teenage alcohol consumption, experimentation with drugs, and bullying through peer support in schools, and to promote a school that is a positive, creative, and stimulating workplace for all. The program was first implemented in one part of the school, and was planned to be extended to the whole school. Subsequent implementation in a second school was planned. However, this extended implementation was only partly carried out due to limited resources. The evaluation included focus group interviews with peer supporters and repeated cross-sectional questionnaires to schoolchildren in school years 7-9 in the two schools.

National Federation SMART: SMART Västernorrland

The main objective of this NGO is to prevent or postpone alcohol, tobacco, and other drug use among children through positive reinforcement and signing of contracts. The parents sign the contract together with their child. The content of these contracts varies between local organizations. The membership gives the child positive benefits reinforcing positive behaviours. The program was implemented in a Swedish county, Västernorrland. The evaluation plan included an effect study among schoolchildren in Kramfors, a study of parents, and an interview of stakeholders in the county. The program was cancelled by the municipality of Kramfors with negative consequences for the effect study, which had been planned as a repeated cross-sectional study of schoolchildren in years 4-9. Data was collected with questionnaires and during the three years, 2,052 children answered the questionnaire. The research team decided to implement the evaluation as planned even if there was no intervention the third year.

The Swedish Youth Temperance Movement (UNF): Folk Beer Project

The Non-governmental organization UNF is a politically and religiously independent organization. They are a sister organization to IOGT-NTO (The Swedish Temperance organization), which is a part of the International Organization of Good Templars. All members are between 13 and 25 years of age. To be a member you have to be a teetotaller. The activities are of different kinds, for example arranging theatrical performances, discos, cafés, study circles, and a large number of courses. Besides dealing with alcohol regulations and politics regarding alcohol, they also work with international exchange and democracy issues. Their vision is a democratic and socially responsible world free from drugs. Although they are politically independent, their task is to act politically in letting the politicians know which issues are important to them. UNF has an almost 40-year history of conducting underage alcohol purchase attempts.

In 2003 UNF applied for funding for a new idea. They wanted to compare two different strategies that included underage purchase attempts. The first was an elaboration of their earlier method, which meant confronting the media with the results of the purchase attempts, reporting the check-out clerks who sold them beer to the police, and informing the municipalities of which stores that sold beer to minors. The other method was based on the idea to actively seek cooperation with the retail grocery sector, the municipality's alcohol administrator or drug coordinator (the municipalities are organized differently), the police, and the labour unions. The evaluation program was designed as a quasi-experimental study and as a follow up of the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and of the effect of different strategies to influence the shops to comply with the law [ 74 ].

Studies of Process and Implementation

Seven of the in-depth studies focussed on the working process in the projects. Three projects were community-based and had a clear geographical area where the programs were implemented. Motgift Gotland was an alliance for preventing the use of narcotics on the island of Gotland. Söder mot Narkotika was also an alliance against narcotics in a central district (Södermalm) of the capital Stockholm. A broad range of agencies and organizations collaborated in these efforts. A third community-based project was run by Verdandi Tensta Rinkeby. The three community-based projects were studied during 2005-2006 and included interviews with stakeholders and actors in the projects. A lesson learned is that community-based prevention needs to have broad support and cannot depend heavily on individual project leaders.

Verdandi: Get safe in Tensta - Rinkeby. Meet us!

An in-depth analysis was made of the third project in order to uncover their successful strategy. Verdandi, founded in 1896, is a Swedish workers' organization striving for social justice and a society free from alcohol-related injuries. From the very beginning, Verdandi - as an independent organization within the workers' movement - has aimed to improve people's social and financial situations. Today's aim is to analyse the development of society through the experiences and voices of those who are not heard otherwise. People of all ages, in all parts of the country, may participate in Verdandi's activities, which are quite different from place to place since they are based on local needs. According to Verdandi, without a local angle, the organization would soon lose touch with reality as well as lose credibility and members.

Verdandi runs activities for youth. The project includes support for children both in school and after. The youth in the organization can use a facility in the neighbourhood in their leisure time. Youth activities have focused on "the young leading the young" and the project has demonstrated young people's ability to organize and run a rewarding activity in the evenings and on weekends. The aim of this prevention program is to empower young people in their daily lives and help them empower their friends. This, according to the organization, contributes to young people avoiding drugs, and the neighbourhood has become calmer and safer. The activity has a bottom-up nature and the youth are involved in the planning. They have the opportunity to develop activities and thereby affect their daily lives. Among the success factors, according to the in-depth study, are: confidence in the organization, equality, youth involvement and power, memberships, support from the parents, training of leaders, common norms and roles, volunteer work, easily accessible premises, and a leadership that facilitates democratic processes.

IOGT-NTO: Dare/Young and King

This program is a redesigned version of the American program DARE [ 79 ], which was implemented before the research group was appointed. However, an adult education component, Young and King, aiming to strengthen parents was implemented and a follow-up study was completed of this component of the program.

IOGT-NTO:s Juniorförbund: Junis sisters

In this project, groups of schoolgirls in years 5 and 6 are organized with the objective to strengthen their self-esteem and promote meaningful leisure activities and thereby delay the onset of alcohol consumption by the girls. The evaluation focused on the group leaders, who were interviewed in focus groups. A lesson learned is that special effort must be put into recruiting and assisting group leaders to achieve sustainable programs.

Makalösa föräldrar: Single Parent with Teenagers

The project consisted of two main parts. One part focused on improving the knowledge about how it is to be a single parent with a teenager in the family. A survey of single parents was done in a part of Stockholm and a small newsletter was produced. The other part included self-help groups for single parents and summer camps. The evaluation of the self-help groups consisted of follow-up questionnaires to participants. An unsuccessful part of the evaluation was the follow-up of the newsletter, which was well planned and properly designed. It was not possible to get feedback from policy-makers on the publication, which may be due to lack of awareness of the publication and its contents.

The Swedish Ice Hockey Association: School Ambassadors

The project aimed to train top athletes to become school ambassadors in order to influence the attitudes of schoolchildren and give them the opportunity to try out ice hockey. Moreover, the project was also an attempt to improve the collaboration between schools and top ice hockey clubs. In the second year the specialized ice hockey secondary schools were included in the program. The evaluation consisted of following up the training of the athletes and studying the work of the secondary school ice hockey players by means of a questionnaire to schoolchildren.

In order to promote the development of a partnership a series of measures were implemented (Table 7 ). All project leaders were invited to regular meetings, which were held in Örebro as well as in Stockholm, Gothenburg, and Malmö. The agenda included presentation of project plans, information from the NBHW, and the research and development activities by the research team. Thematic lectures and discussion on issues such as the art of project management, measures to reach target groups, media advocacy, Internet as a tool for prevention, and planned communication were held at different meetings. The main objective of these meetings was to promote exchange of experiences and learning in order to strengthening the quality of the implementation of the projects as well as networking. Moreover, the systematic bi-annual and annual reports were introduced and discussed.

Depending on the needs of the different projects special project dialogues and consultations were held between individual projects, or a small group of similar projects, and the research teams. The results of these meetings ranged from refinement of project ideas to long-term collaborations. All in-depth studies started with such meetings. The competence development took different forms. In the first period an academic training program in alcohol and drug prevention was offered to the project leaders, of whom about 10 participated. Supervision in groups was implemented in three groups during the first two years, and thereafter one or two groups were run by independent supervisors annually. During 2009 the research team arranged more project leader meeting including training in project management as an alternative to supervision.

The in-depth studies were also an important measure to foster the partnership between the NGOs and the research team. Due to available resources, more extensive process and effect evaluation activities could only be implemented in a limited number of projects. Many more projects asked to be the focus of in-depth studies than the fourteen that were initiated.

The research team together with the NBHW arranged a national conference Reflections on prevention - Collaboration for better alcohol and drug prevention. Conferences were arranged in the spring of 2006, 2008, and 2010. Among the key issues discussed at the first conference were the role of parents in prevention, adolescents, community-based approaches, and supply-reducing initiatives. The second conference also discussed the role of civil society and how to promote more effective cooperation among the different stakeholders. The third conference focussed on evidence and evidence-based practice, which have received increased attention in Sweden in many sectors of society. A main emphasis has been setting the context for reflection and sharing of experiences among the participants at the conferences; therefore a series of seminars with project presentations and panel discussions have been part of the conferences. Moreover, plenary sessions as well as theatrical performances further set the stage for professional dialogues on alcohol and drug prevention. The conferences have been well received and have attracted actors from different sectors of society as well as national agencies and NGOs.

In the annual reports the project leaders also assess the implemented measures by the researchers. These have guided the future efforts of the research team. As an example, the assessments made in January 2005 are presented in Figure 4 . The financial support was very important, followed by the support from the NBHW, the project leader meetings, and the supervision. One third of the project leaders regarded the support for the documentation as very important. The academic training in alcohol and drug prevention was regarded as very important by one fifth of the project leaders, which is a high proportion given that only a small group participated in the distance education course. Only eight projects were at that time included in the in-depth studies, nevertheless one third of the project leaders reported this measure as very important. The case study data bank includes information for questionnaires, interview and other data sources for the assessment of the implementation of the research strategy.

Assessment by project leaders of measures to improve collaboration between NGO and research in 2006 .

The research strategy has been successfully implemented despite the fact that only some projects were running more than one year while new projects and project leaders are included every year. The first two years a focus in the meetings with the project leaders was on the in-depth studies which were presented by the organisations and the researchers. Then the focus changed to addressing common concerns among the project leaders such as how to reach target groups, use of Internet, different type of prevention projects and mass communication skills. The presentations from the research teams were more concentrated to the national conferences that were organized bi-annually. The networking between the projects also resulted in new applications jointly by two organisations.

An important element was the relationship between the NBHW and the research team at Örebro University. During this period the NGO portfolio was managed at the NBHW by the same senior official. However, the department director changed three times during this period. The members of the working committee also changes over the years. The chairman was the same during all years. The support to the research and development activities was nevertheless maintained and also renewed for another year. The continuity with regard to persons seems to be very important for such an endeavour as included in this case study.

Discussion - towards practice-based research for alcohol and drug prevention

The integration of the research and development component into the support from the NBHW resulted in a unique possibility to do comparative studies involving, among other things, project management and implementation as well as project results. The measures to promote a partnership for practice-based research also improved the quality and success of the different projects. A few of the in-depth studies were unsuccessful due to factors hindering the implementation, and in several cases these factors were related to a lack of resources on the part of collaborating partners in the municipalities or other organizations.

The research strategy has been based on the overall aim to contribute to the evidence base for alcohol and drug prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. The current development of practice-based research will give more relevant knowledge and our research program attempts to be a part of this trend. Moreover, the utilization of research results may also be improved if studies on efficacy, effectiveness, and dissemination are promoted [ 18 ]. The strategy that the NBHW developed in this program of governmental support to NGOs was an attempt to bridge this gap as described by Nutbeam [ 10 , 11 ]. This challenge for agencies to respond to the push from the funders and pull from the communities has been noted by Green and Mercier [ 23 ] and the public health researcher also needs to leave the university campus to get involved in more practice-based research. Our research program has developed along such lines.

The research strategy includes the use of qualitative, quantitative, and mixed methods. This means that data collection and data analysis are done using guidelines for these three traditions. The challenge is most apparent with regard to inference and integration. In the stages of inference in a study, quality issues such as internal and external validity in the quantitative approach and aspects of credibility, confirmability, and transferability in the qualitative approach are pertinent. Integration is the mixed-methods approach of working across strands and using meta-inferential issues related to the integration of findings and inferences from the two strands. Here design quality, interpretative rigour, and inference transferability have been proposed as indicators of quality [ 70 ]. In this research strategy case study, the set of research entities changed each year due to the funding of applications from NGOs by the NBHW. The present study covered a six-year period, and the stages of inference and integration were completed yearly in the preparation of the annual reports to the NBHW.

The research strategy also includes elements of participatory research. The organizations were involved in developing the main research questions in the in-depth studies. Sometimes the organizations also assisted in collecting questionnaires from school children; in making participatory observations, as in the studies of beer purchasing by minors; or in providing feedback to school staff and target groups, as in the parental support programs. Moreover, the organizations also played a role in discussing preliminary results as part of a validating process for the empirical studies. These discussions never changed the interpretations of the findings but often gave more insight into the noble art of implementation of preventive programs. Nevertheless, as in other research programs, a number of methodological challenges had to be dealt with. The resources were limited, which gave room for only a small number of in-depth studies. Therefore the research strategy included additional elements such as support to documentation as well as support to the project leaders in meetings and management training. The selection of these studies was mainly done by the steering committee at the NBHW. The research team developed a proper design for these studies based on the assessed potential for a successful implementation and possible options given the resources available for effect or process studies. Then the choice of methods for data collections was reviewed and target groups for the evaluation research selected. In this process the best choice from an academic point of view was often not possible due to limited staff and other resources. Nevertheless, the research program resulted in data collected from 9,568 children, 4,832 parents and 327 actors or stakeholders. Moreover, it was possible to carry out two large longitudinal studies of children and their parents in this research program. Even if the funding was granted annually, it was possible to think and plan on more long-term basis.

A broad range of organizations received project funding from the NBHW. Although the largest number of projects was run by the nine alcohol and drug organizations, the alcohol and drug prevention was successfully integrated into a range of organizations with other main objectives. Moreover, the project leaders also came from different societal sectors. This was an intended effect of the governmental initiative to strengthen the alcohol and drug prevention in Sweden. This led to another methodological challenge caused by the fact that the programs were so different. The research team developed questionnaires with common modules that could be used in different evaluations thus giving them access to data from schoolchildren and parents in different contexts and programs. This made it possible, for instance, to study the reasons for non-participation in parental support programs [ 73 ]. Another added value related to this was the possibility to organize a study of project management through a special study of the project leaders, which was integrated into the overall design of the support from the NBHW.

A challenge for the research team was that the funding for the research as well as for the alcohol and drug projects was decided annually by the NBHW. However, the research was planned with a longer time period in mind, which has actually led to a research program that has been running more than six years. A more long-term grant would have been beneficial for the development of a partnership between the NGOs and the research team. In order to overcome this barrier a multi-year agreement has been signed for the newer in-depth studies, but it was still signed on the condition of renewed funding the following year. Nevertheless, a trustful partnership was developed between all three partners: the practitioners in the NGOs, the national agencies, and the researchers. In many cases the planning and implementation were done jointly, dividing the responsibilities according to skills and keeping the roles clear and feasible to complete successfully. The validity of the results was also a major concern as well as an emphasis on a participatory approach to the research process.

Ethical concerns were very important, as stipulated by Swedish law. The effect studies were assessed by the regional research ethics boards. However, it is also important to analyse if the NGOs have vested interests in the research process. Government agencies as well as NGOs can also have a vested interest in scientific research, such as when science is misused to benefit a particular political agenda, ideology, or favoured interest group [ 80 ]. However, the problem of vested interests is more dangerous when key parts of the government sector are in conflict over their public health responsibilities; for instance health sector engagement in partnership arrangements with addictive consumption industries (particularly alcohol, tobacco, and gambling) entails too many risks [ 81 ]. In our case there have been shared visions and objectives between the government agency and the NGOs, which guided the developmental activities as well as the research work. Moreover, the division of responsibilities between the NGOs and the researcher was important. The NGOs had the responsibility for developing the proposals, conducting the interventions, and implementing the preventive programs or initiatives. The researchers had the responsibility for planning the effect evaluations after consulting with representatives of the NGOs, as well as for implementing the research components, analysis, and reporting of results, including dialogues about the outcomes, and presenting the findings for the NGOs.

The organization of the research program under the auspices of public health science at Örebro University was natural as the principal investigator holds a professorial chair in public health there. During the first two years, other members of the research group were formally employed by an NGO but worked at the university campus in Örebro. All members of the research team were subsequently offered employment at the university, giving the research team a formal independence from all NGOs.

The addiction research centres have mandates that are broader than the present research program. The centre in Michigan has the mission to develop new knowledge about the cause, course, and consequences of substance use disorder and to train the next generation of researchers [ 28 ]; and the Canadian centre in British Columbia to create an internationally recognized centre distributed across BC that is dedicated to research and knowledge exchange on substance use, harm reduction, and addiction [ 27 ]. The Swiss institute is primarily involved in collecting alcohol-related information and making it available to professionals and the general public. The Swiss Institute will continue to monitor substance use, while stepping up its prevention research activities and ensuring that it is able to react promptly to emerging phenomena [ 25 ]. Our small research team is attempting to fill a gap in knowledge about the NGO alcohol and drug prevention efforts as these offer unique opportunities [ 82 ].

The research strategy was successful in establishing prevention research for alcohol and drug prevention by NGOs, which previously had been lacking in Sweden. Moreover, added value came from having meetings for project leaders, and the capacity building led to new innovative collaboration between different NGOs, which resulted in new applications for funding and successful implementation of new initiatives. The administrative support for improving the documentation of the implementation and progress of the projects was also recognized as beneficial for the practitioners and the national agency as well as the researchers. The best approach is always transparency and discussion, disclosure and debate [ 83 , 84 ].

A weakness in the research strategy was that the funding was not sufficient for more than a limited number of in-depth studies. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. It was beneficial because it gave the research team opportunities to address other issues. From a strictly research point of view it would have been of interest to see what could be achieved by researchers-as-designer , but this would have been very costly and all funds allocated to the integrated research activities would have been consumed by just one project. In other words, the present research strategy can be regarded as cost-effective.

The overall strategy for research and development includes capacity building for both the practitioners in the NGOs and the research team, and two doctoral dissertations will be finalized during the coming year. The NBHW has also noted that, given the limited duration of funding, this organization of knowledge development - as an integral part of the support to NGOs - is beneficial, which is indicated by the annual renewal of the contract with Örebro University. Moreover, the much more extensively funded projects in municipalities, regions, and counties still lack this strategic element. At present there is a trend that some larger governmental grants are given to such parties, but a mandatory linkage to universities for research is included in the call for proposals. This could lead to similar forms of trustful partnerships as found in the present research strategy case study.

The in-depth studies in this research strategy varied in content, design, and size. A common element was that they were program-driven and not research-driven interventions [ 9 ]. This may give the studies improved external validity [ 54 ]. The research strategy aimed at improving the evidence-base for alcohol and drug prevention. In our case this has meant using qualitative, quantitative, and mixed methods, as well a variety of designs to answer questions in practice-based settings. Including feedback and dialogue with the NGOs has further contributed to sustainable AD prevention in different settings. The missions of the NGOs differ, but the AD prevention has been included as an essential part of their activities, which in many cases meant that AD prevention has received increased priority. Moreover, the integrated research program has also been seen as beneficial and important for the organizations, which often wanted their programs to be recognized as evidence-based. Therefore, the demand for research by the NGOs is larger than what we can supply at present. This is a challenge to the funding agencies as well as research bodies. The addiction research centres seem to nurture creativity but often lack the networks and priorities for preventive research. It is important to go beyond the notion that a lack of evidence for a program is necessarily a sign of a lack of effectiveness. Therefore, practice-based research and collaboration between decision-makers, national agencies, NGOs, local authorities and researchers is needed. Using a combination of different and interactive measures it was possible to over the years built a trustful partnership between these parts. This research strategy case study shows that it is possible even in such a dynamic field as alcohol and drug prevention in NGOs where the organisations are competing for grants from the NBHW. There are added values in supporting a research group assigned to a project portfolio instead of having a series of smaller independent evaluations.

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organizations. Competence development is necessary for developing evidence for policy and practice. Given research groups assignments to address the knowledge development issues is better than having minor evaluation in individual projects. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

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Acknowledgements

The authors are very grateful to all the NGOs that have shared their efforts and experiences with the research team. We would also like to acknowledge Åke Setréus for his support and encouragement during the whole period. The Swedish National Board of Health and Welfare supported the study.

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The four authors of the manuscript are presented in alphabetical order and their shares of the responsibility for the paper are equal. CE is the principal investigator for the research program integrated in the NBHW support to NGOs for alcohol and drug prevention. CE, ML, and CP were involved in all aspects of the program as well as this study. SG was involved in the planning, project implementation, and writing of the section on NGOs. All authors read and approved the final manuscript.

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Eriksson, C., Geidne, S., Larsson, M. et al. A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009. Subst Abuse Treat Prev Policy 6 , 8 (2011). https://doi.org/10.1186/1747-597X-6-8

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

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Forensic appraisal of death due to acute alcohol poisoning: three case reports and a literature review

a Department of Forensic Medicine, School of Basic Medical Sciences, Fudan University, Shanghai, China

b Institute of Criminal Scientific Technology, Shanghai Public Security Bureau, Pudong Branch, Shanghai, China

c Forensic Laboratory, Criminal Science and Technology Institute, Shanghai Public Security Bureau, Shanghai, China

Death due to acute alcohol poisoning lacks specific anatomical characteristics, compared with other deaths due to drug poisoning. We report three forensic cases of death from acute alcohol poisoning due to inhibition of the respiratory centre and eventual asphyxia. Blood alcohol concentrations in the three fatalities were 5.28, 3.33 and 3.78 mg/mL, respectively. Lethal doses and blood alcohol concentrations showed differences between individuals. Detailed auxiliary tests besides autopsy were undertaken. These cases show that forensic scientists should exclude other causes of death, combine the autopsy with auxiliary tests, and then make an appraisal.

Introduction

Alcohol is the psychoactive substance encountered most often in forensic toxicology [ 1 ]. Moderate consumption of alcohol can reduce the risk of cardiovascular diseases and type 2 diabetes mellitus [ 2 ], contribute to formation of positive and optimistic lifestyles, and improve quality of life [ 3 ]. However, alcohol abuse can trigger alcohol-related diseases, a trend of consuming alcohol at a younger age, and can lead to violent behaviour [ 4–7 ]. At high blood alcohol concentrations (BACs; >4 mg/mL) people are likely to harm themselves or suffer blunt trauma through accidental falls [ 8 ].

Alcohol abuse can also cause death. According to World Health Organization reports, ∼3.3 million people worldwide die due to alcohol consumption each year, which accounted for 5.9% of all deaths in 2012 [ 9 ]. Excessive consumption of alcohol can cause death by drowning, traffic accidents or violence. A study in Slovakia showed that death due to acute alcohol poisoning (AAP) accounts for a significant proportion of all deaths related to alcohol consumption [ 10 ]. Similar results have been found in women [ 11 ]. Death due to AAP is a serious consequence of heavy drinking. Alcohol can inhibit the central nervous system (CNS), cause respiratory depression and, eventually, lead to death by asphyxia [ 12 , 13 ]. Autopsies of cases of death due to AAP lack specific anatomical–pathological findings, compared with other subjects within forensic medicine. Forensic scientists must, therefore, exclude other suspicious causes of death and combine auxiliary tests to reach the correct conclusion.

In forensic medicine, prior alcohol consumption and the quantity of alcohol intake are important for determination of responsibility of criminal and civil cases. It is important to judge death by AAP correctly. We assessed three fatal cases of AAP and, combined with a literature review, conducted a retrospective analysis and appraisal of AAP cases leading to death.

Case presentation

A 44-year-old male was found deceased at home at 10 pm. After collection, his body was stored frozen. We conducted an autopsy 10 days after his death. External examination showed that his face, lips and nails were marked by cyanosis. A small rupture (0.3 cm × 0.3 cm) was found on his right occipitalis muscle. Internal examination revealed a thickened intima and lipid deposition in the left anterior descending coronary artery (LADCA), type-I stenosis of the LADCA lumen, cardiac and pulmonary interstitial congestion, severe pneumo-oedema and light haemorrhage of the gastric mucosa ( Figure 1 ). The pathological diagnosis was: (1) severe pneumo-oedema, (2) cardiac and pulmonary congestion, and (3) small rupture of the right occipitalis muscle (0.3 cm × 0.3 cm).

Light haemorrhage of the gastric mucosa (arrow).

Central blood (without a fluoride preservative) and gastric contents were taken for toxicology testing, and samples were stored at 4 °C before testing. The BAC was estimated by headspace gas chromatography using a method described previously [ 14 ]. A total of 0.10 mL of blood was diluted with tert-butanol (40.0 µg/mL; 0.50 mL as the internal standard). The same method was employed for the two cases described below. Toxicology testing showed that the BAC was 5.28 mg/mL. Common toxins, including hypnotic sedative drugs, insecticides and tetramine, were not detected in the submitted samples of blood or gastric contents. After investigation, we found that this man had consumed a whole bottle (500 mL) of spirit (ethanol content: 52%) at noon on the same day that he died. Thus, we concluded that this man’s cause of death was consistent with AAP.

The deceased was a 27-year-old female. She drank ∼450 mL of Hennessy cognac (ethanol content: 40%) with some people over the span of one night, and then went with other people to a restaurant, where she drank ∼150 mL of spirit (ethanol content: 35%). Subsequently, the woman slipped into a coma and was sent to a hospital. The attending physicians gave her an intravenous drip, but the woman died. The clinical diagnosis noted that the woman had drunk alcohol before slipping into a coma, her breathing and heartbeat had stopped, and her carotid pulse had disappeared by the time the ambulance arrived. After collection, her body was stored frozen.

We conducted an autopsy 17 days after her death. External examination showed that the face, lips and nails of both hands were marked by cyanosis ( Figure 2 ). There was an injection-needle mark on the dorsum of her left hand which was set during medical treatment. Internal examination revealed pale-red oedematous fluid in some alveolar spaces. The pathological diagnosis was pneumo-oedema due to alcohol consumption. Central blood (without a fluoride preservative) was taken for toxicology and stored at 4 °C before tests. Toxicology revealed the BAC to be 3.33 mg/mL. Blood tests (monoclonal antibody board test) for morphine, pethidine, cocaine, marijuana, ketamine, methadone, amphetamine and methamphetamine were negative. Thus, we concluded that the woman’s cause of death was consistent with AAP.

Lips (A) and nails of both hands (B) were marked by cyanosis.

A 19-year-old male who had been healthy was found in an abnormal state at ∼10 pm after drinking two paper cups of spirit (ethanol content: 36%) and a paper cup of beer (ethanol content: 8%) at a party. The capacity of each paper cup was ∼250 mL. Without too much delay, he was sent to a hospital, but efforts to revive him proved futile. After collection, his body was stored frozen.

We conducted an autopsy 18 days after his death. External examination showed his lips and nails to be marked with cyanosis. There was an injection needle mark on the dorsum of his left hand (due to insertion of an intravenous drip at the hospital). Internal examination revealed some meaningful signs. The cut surface of the lungs showed congestion, and there were some small haemorrhagic spots on the lung bases ( Figure 3 ). Most of the alveolar space was filled with pale-red oedematous fluid. The schistose regions of alveolar spaces were filled with red blood cells. Blood capillaries of alveolar walls were ectatic and congestive, and pulmonary interstitial congestion was present. A few haemorrhagic spots were observed on the schistose regions of the fundus gastric mucosa. A high level of congestion was found in the blood vessels of the gastric mucosa. Subarachnoid and cerebral parenchymal vascular congestion were also documented. The pathological diagnosis was: (1) pulmonary congestion, pneumo-oedema and localized pneumorrhagia, (2) focal haemorrhage of the gastric mucosa, and (3) cerebral haemorrhage and encephaloedema. Central blood (without a fluoride preservative), urine and gastric contents were taken for toxicology testing, and all samples were stored at 4 °C before testing. Toxicology testing revealed the BAC to be 3.78 mg/mL. Urinary tests for opioids, amphetamines and ketamine were negative. Hypnotic sedative drugs, insecticides or tetramine were not detected in his blood, urine or gastric contents. After investigation, we found that this man drank alcohol heavily at the party and had not slept well for 2 days previously. Thus, we concluded that the cause of this man’s death was consistent with AAP.

Small haemorrhagic spots on lung bases (arrow).

Discussion and conclusion

The relationship between CNS depression and alcohol intoxication has been demonstrated [ 13 ]. Hence, people who appear to die from AAP often have asphyxia-related features. The three cases reported in the present study exhibited some important signs of asphyxia, such as cyanosis of the lips and nails, pneumo-oedema, pulmonary congestion and alveolar spaces being filled with pale-red oedematous fluid under microscopic examination. In Case 1, there was some haemorrhage in the gastric mucosa. In Case 3, we found some haemorrhagic spots on the schistose regions of the fundus gastric mucosa. These features were caused by acute injury to the gastric mucosa due to excessive consumption of alcohol. Alcohol can stimulate the gastric mucosal epithelium and submucosal vessels directly, and can change hormone levels in the gastrointestinal tract by mediating inflammation and thereby aggravating gastric mucosal injury [ 15 , 16 ].

The autopsy results of AAP-related death are not specific, so we should exclude other causes of death, such as sudden death, mechanical injury, mechanical asphyxia or electrocution. Alcohol intake is a risk factor for sudden cardiac death [ 17 ]. In Case 1, we found a thickened intima, lipid deposition in the LADCA and type-I stenosis in the LADCA lumen, but the latter was too light (Grade I: lumen area decreased by 1%–25%) to interrupt the cardiac blood supply, let alone cause cardiac arrest. We did not find pathological changes leading to sudden cardiac death either, so we ruled out this possibility. In addition, although a rupture (0.3 cm × 0.3 cm) was found on the right occipitalis muscle, its range was limited, and we did not detect a skull fracture or obvious intracranial haemorrhage. Therefore, we could exclude death by craniocerebral injury. Alcohol intoxication can result in vomiting, food regurgitation and paralysis of the pharyngeal reflex, which make it easier to die from asphyxia via aspiration of gastric contents [ 18 ]. According to the anatomy of asphyxia-related death caused by aspiration, vomit in the trachea, bronchi and bronchioles may be found. In the three cases reported here, there was no blockage in the trachea, bronchi or bronchioles due to foreign bodies.

In addition to autopsy, we used auxiliary tests, including a BAC test and other routine toxicology tests, to determine the cause of death. Through case investigations, it has been established that AAP-related death is often associated with a history of heavy drinking. Compared with chronic alcoholism, AAP shows a higher BAC but the acetone concentration is not increased remarkably. These findings may be related to alcohol-related damage to organs and tissues, chronic tolerance to alcohol, positional asphyxia/suffocation, hypoglycaemia or ketoacidosis [ 19 ].

Different authorities have different views on the lethal blood concentration associated with AAP, and range from 3.50 to 4.00 mg/mL [ 4 , 20 ]. The mean BAC in 175 fatal cases recorded by Heatley and Crane [ 21 ] was 3.55 mg/mL. As a result of differences between individuals, the lethal threshold of the BAC is undefined and seems to be lower than conventional acknowledgement [ 22 ]. Jones [ 23 ] stated that the BAC of a driver in Sweden was >5.00 mg/mL but he was alive. The lethal dose of alcohol is related to sex, age and genetic factors, though the speed of alcohol consumption, type of beverage and drinking habits can also exert influences. Li et al. [ 24 ] showed that, in AAP-related death, overweight drinkers showed more significant BAC levels for the heart and peripheral circulation than normal-weight drinkers. The BAC in the three cases in the present study was 5.28, 3.33 and 3.78 mg/mL, respectively. Because of the high BAC in Case 1 (5.28 mg/mL), there is little doubt that the cause of death was AAP. In Case 2, the deceased consumed a large amount of high-alcohol-concentration spirit, which may resulted in a decrease in alcohol tolerance. She had a history of coma before death, which confirmed that her BAC had reached a lethal concentration. In Case 3, the deceased was only 19 years of age. Compared with adults, adolescents are more sensitive and less tolerant to alcohol [ 13 ]. Further investigation revealed that the deceased drank quickly and had not slept for 2 days before the incident, which may have reduced his tolerance to alcohol. A history of intravenous-drip rescue was found in Cases 2 and 3, which may have led to the decline in the BAC. The relationship between alcohol intake and the BAC is expressed by the Widmark formula [ 25 , 26 ]:

where BAC represents blood-alcohol concentration in mass/mass unit; BWt represents the body weight (kg); A represents the quantity (g) of alcohol absorbed and distributed in all body fluids and tissues at the time the blood sample was taken; and the rho-factor differs in different individuals. This formula provides a preliminary inference of the BAC, and verifies the accuracy of the case investigation and BAC-test results.

Results of ethanol determination in specimens postmortem can be affected by several factors, of which putrefaction and diffusion of gastric contents postmortem are the most common [ 1 ]. Ensuring timely submission to the test after death and keeping corpses frozen to inhibit bacterial activity can reduce the interference of putrefaction postmortem. Currently, n-propanol is used as an internal standard. However, the theory has been invalidated that if the deceased did not have prior alcohol consumption, the ratio of alcohol/n-propanol in his/her blood should be <20 [ 14 ]. Therefore, the expected ratio of alcohol/n-propanol must be determined.

Ethyl glucuronide (EtG) and ethyl sulfate (EtS) are products of alcohol metabolism, and can be produced only by enzymatic metabolism from the body. Under some circumstances, analyses of these ethanol metabolites can be useful to estimate putrefaction postmortem. However, EtG has a long half-life and may be unstable at 30 °C or 40 °C if blood samples are stored without preservatives [ 14 ]. Therefore, EtG cannot show that alcohol consumption is related directly to the death, and is not suitable for highly putrefactive corpses.

The urine alcohol concentration (UAC) can help to analyze alcohol metabolism. The UAC/BAC ratio could help to ascertain if the absorption and distribution of alcohol in all fluids is complete. Usually, a low ratio (both mean and median, 1.18:1) suggests that alcohol has been absorbed and distributed completely [ 27 ].

Besides its watery nature, the vitreous humour is less affected by bacterial spread from the intestinal tract, which makes it undergo less putrefaction post-mortem and has less redistribution postmortem [ 1 ]. Therefore, it can be used as a substitute and reliable assessment if blood is deficient or if there is putrefaction or redistribution postmortem [ 28 ].

Our three cases were sent for autopsy and toxicology tests 10, 17 and 18 days after death but the bodies were frozen, and organ autolysis was not obvious according to histology. Thus, we consider the BAC results to be reliable. Usually, the liquor pericardii exhibits the highest alcohol concentration, followed by the left pulmonary vein, aorta, left heart, pulmonary artery, superior vena cava, inferior vena cava, right heart, right pulmonary vein and femoral vein, in decreasing order [ 29 ]. Therefore, taking femoral venous blood simultaneously for a BAC test may help reduce the error from diffusion of gastric contents.

In fatal cases of AAP, detection of other drugs is not infrequent, of which diazepam is predominant [ 30 ]. Alcohol can interact with other drugs and promote their toxicological effects. Studies have shown that alcohol consumption increases the risk of death for heroin users [ 31 ]. Methamphetamine and cocaine can enhance the toxicological effects of alcohol [ 32 ]. Meanwhile, the BAC decreases if the number of other drugs in blood increases, which has an impact on results [ 33 ]. There are cases of death due to alcohol combined with other poisons (e.g. injecting drugs while consuming alcohol). Indeed, some criminals taint alcoholic beverages to commit crimes. In China, there is a tradition of drinking medicated wine, which may contain toxic components such as venin or aconitine [ 34 ]. Therefore, for cases of death due to AAP, routine toxicology tests should be done to exclude the possibility of death by other poisons. There are many types of toxic substances, so some rare toxic substances may be omitted from routine toxicology analysis. Thus, it is necessary to combine the autopsy, case details, and the crime-scene investigation with toxicology tests to make a comprehensive analysis. In all three cases, routine toxicology tests were carried out, and we did not find other meaningful discoveries through case investigation and autopsy. Therefore, other poisons could be excluded from the causes of death.

In recent years, extensive studies have interpreted how alcohol-induced inhibition of the respiratory centres in the brainstem help explain the cause of AAP-related death. Acute exposure to alcohol can influence synaptic transmission, break the delicate balance between excitatory and inhibitory neurons in the CNS, and inhibit brain functions by altering cell membranes, ion channels, enzymes, neurotransmitter receptors, and the proteins involved in intracellular signal transduction [ 35 , 36 ]. In pre-synaptic signalling, the main function of alcohol is to increase the release of γ-aminobutyric acid (GABA). According to in vivo and in vitro studies, alcohol intake can increase the GABA concentration significantly in some brain regions (amygdala, hippocampus, brainstem) and cause a dose-dependent increase in GABA release in Purkinje cells [ 37 , 38 ]. Recent studies have suggested that release of intracellular calcium, protein kinase A (PKA), protein kinase C (PKC) and adenylate cyclase have roles in this increase in the GABA concentration [ 39 ]. In post-synaptic signalling, alcohol acts mainly on neurotransmitter receptors and affects their functions. Alcohol has a non-competitive inhibitory effect on N -methyl- d -aspartic acid receptors, which are highly sensitive to acute exposure to alcohol by inhibiting calcium influx [ 40 ]. Furthermore, alcohol can strengthen the affinity between GABA and GABA receptors, increase influx of chloride ions, and enhance the long-term depression of GABA A receptors [ 41 ]. Experiments have shown that PKC is necessary for the alcohol-induced potentiation of GABAergic function, and that PKCσ plays an important part in activation of σ-subunit-containing GABA A receptors [ 41 , 42 ]. Alcohol can also act directly on the hydrophobic domain of 5-hydroxytryptamine-3 (5-HT 3 ) receptors, where it makes the opening of these channels more stable, potentiates the function of 5-HT 3 receptors and, eventually, enhances CNS depression [ 43 , 44 ].

As stated above, the forensic appraisal of AAP-related death should pay attention to four main features. First, the case information must be considered, detailed questioning of witnesses should be conducted, and the scene should be surveyed carefully. People who have died due to AAP often have a history of alcohol abuse. Empty or partially empty bottles of alcoholic beverages — or even vomit — can be found at the scene of death. Investigators should pay attention to and collect suspicious items, such as physical evidence on the body and clothing of the deceased. If there is suspicion that the deceased had consumed adulterated wine or medicinal liquor or had been poisoned with toxic substances other than an alcoholic beverage, all of the edible food, drink, and vomit should be sealed and sent for testing. Data from video surveillance can, in some cases, help clarify the activities of the deceased and other details. The second feature is a complete and detailed autopsy. Suspicious injuries or abnormal body conditions/phenomena postmortem should be looked for. AAP-related death exhibits asphyxiation and excludes other causes of death, such as mechanical injury, mechanical asphyxia or electrocution. The third feature is common forensic toxicology testing (e.g. BAC). To eliminate interference by diffusion of gastric contents, blood from the femoral vein should be taken for toxicology testing. Samples of urine and the vitreous humour can be taken simultaneously, if necessary. For highly putrefactive corpses, extraction of the vitreous humour can be attempted for testing [ 45 ]. Meanwhile, routine toxicology tests should be carried out and combined with the case investigation and autopsy. The toxicological effects of different drugs and their blood concentration should be analyzed to determine the true cause of death and the potential role of alcohol. The final feature is a comprehensive analysis of various factors. When considering deaths after alcohol intake, investigators should not simply classify these cases as AAP-related death based on their first impressions, but instead should exclude other suspicious factors to ensure a strict and accurate forensic appraisal.

Authors’ contributions

Hui Wang drafted the manuscript; Hongmei Xu helped to draft the manuscript and polished the language; Wencan Li, Beixu Li and Qun Shi carried out the autopsy of three cases; Kaijun Ma and Bi Xiao helped to collate three cases; Long Chen conceived of the manuscript and helped to draft the manuscript. All authors contributed to the final text and approved it.

Compliance with ethical standards

All procedures undertaken in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee, and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. We declare that the present study complies with current Chinese law. Informed consent was obtained from each individual's family in this study.

Disclosure statement

The authors declare that they have no conflict of interest.

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