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CORK Bibliography: Detection of Substance Use Problems



85 citations. 2003 to present

Prepared: June 2012



Aalto M; Pekuri P; Seppa K. Obstacles to carrying out brief intervention for heavy drinkers in primary health care: A focus group study. Drug and Alcohol Review 22(2): 169-173, 2003. (34 refs.)

The objective of this study was to identify possible obstacles to carrying out competent early identification and brief intervention (EIBI) of heavy drinkers in primary health care. Qualitative focus group discussion method study applying the deductive framework approach. Six focus groups involving 18 general practitioners and 19 nurses were recruited from primary health care of the City of Tampere, Finland. Possible obstacles are: (1) confusion regarding the content of early-phase heavy drinking, (2) lack of self-efficacy among primary health care professionals, (3) sense of lacking time needed for carrying out brief intervention, (4) not having simple guidelines for brief intervention, (5) sense of difficulty in identifying of early-phase heavy drinkers, and (6) uncertainty about the justification for initiating discussion on alcohol issues with patients. The main actions to be taken to promote brief intervention are to educate professionals about the content of early-phase heavy drinking and to produce directing, but not excessively demanding guidelines for carrying out EIBI. Probably successful personal experiences carrying out EIBI can improve professionals' self-efficacy and give to them final justification for discussion alcohol issues with their patients.

Copyright 2003, Australian Medical and Professional Society on Alcohol and Other Drugs


Agabio R; Marras P; Gessa GL; Carpiniello B. Alcohol use disorders, and at-risk drinking in patients affected by a mood disorder, in Cagliari, Italy: Sensitivity and specificity of different questionnaires. Alcohol and Alcoholism 42(6): 575-581, 2007. (39 refs.)

Aims: (i) To evaluate the prevalence of alcohol use disorders, and at risk-drinking among outpatients admitted to the Division of Psychiatry, University of Cagliari, Italy, for mood disorders, and (ii) to compare the sensitivity and specificity of the questionnaires used. Methods: Fifty-six patients affected by mood disorders answered to the questions of (i) The NIAAA Guide for identification of at-risk drinking, (ii) AUDIT questionnaire, (iii) The CAGE questionnaire and, (iv) SCID-I application forms for mood and alcohol use disorders. Results: Fourteen subjects (25%) met the criteria for alcohol use disorders according to SCID-I; 17 (30.4%) achieved a score 1 in CAGE questionnaire; 12 (21.4%) reached AUDIT scores of 8 and 4 for men and women, respectively; 12 (21.4%) provided positive answers to NIAAA Guide. Despite these prevalence rates, no diagnosis of alcohol use disorders had previously been registered in their medical records. The CAGE questionnaire achieved the highest values of sensitivity and specificity in detecting alcohol use disorders tested against that of the SCID-I. Conclusions: Alcohol use disorders and at-risk drinking are frequent in patients affected by mood disorders, although often underestimated; this underestimation was virtually absolute in the sample of patients investigated. Combination of the CAGE questionnaire plus the first questions in the NIAAA Guide may be an effective tool for use in the identification of psychiatric patients with possible alcohol use disorders or at-risk drinking.

Copyright 2007, Oxford University Press


Aira M; Kauhanen J; Larivaara P; Rautio P. Factors influencing inquiry about patients' alcohol consumption by primary health care physicians: Qualitative semi-structured interview study. Family Practice 20(3): 270-275, 2003. (26 refs.)

Background. Early recognition of and intervention in risky alcohol consumption has been shown to be an effective way to reduce the harm. However, primary care physicians are still not screening for and intervening sufficiently in their patients' alcohol misuse. Objective. The purpose of this study was to explore factors having an effect on primary health care physicians inquiring about patients' alcohol consumption. Method. A qualitative study of primary care physicians' experiences and views based on tape recorded semi-structured interviews was carried out on all physicians (n = 35) working at four health centres in Eastern Finland. Results. Seven main categories were identified that either prevent or promote discussion about alcohol consumption: the sensitive nature of alcohol drinking; the reason for consultation; awareness of a patient's alcohol problem; patient factors; availability of intervention tools; expectations of effectiveness of interventions; and lack of time. Conclusions. There still exist many barriers to initiating discussions about alcohol in the consultation room. Changing the frame of reference of the concept of alcohol drinking from an addictive disease to a general lifestyle risk factor could overcome many of these barriers.

Copyright 2003, Oxford University Press. Used with permission


Anderson CE; Loomis GA. Recognition and prevention of inhalant abuse. American Family Physician 68(5): 869-874, 2003. (22 refs.)

Inhalant abuse is a prevalent and often overlooked form of substance abuse in adolescents. Survey results consistently show that nearly 20 percent of children in middle school and high school have experimented with inhaled substances. The method of delivery is inhalation of a solvent from its container, a soaked rag, or a bag. Solvents include almost any household cleaning agent or propellant, paint thinner, glue, and lighter fluid. Inhalant abuse typically can cause a euphoric feeling and can become addictive. Acute effects include sudden sniffing death syndrome, asphyxia, and serious injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can damage cardiac, renal, hepatic, and neurologic systems. Inhalant abuse during pregnancy can cause fetal abnormalities. Diagnosis of inhalant abuse is difficult and relies almost entirely on a thorough history and a high index of suspicion. No specific laboratory tests confirm solvent inhalation. Treatment is generally supportive, because there are no reversal agents for inhalant intoxication. Education of young persons and their parents is essential to decrease experimentation with inhalants.

Copyright 2003, American Academy of Family Physicians. Used with permission


Banta JE; Montgomery S. Substance abuse and dependence treatment in outpatient physician offices, 1997-2004. American Journal of Drug and Alcohol Abuse 33(4): 583-593, 2007. (23 refs.)

Objective: To examine patient, physician, and visit characteristics associated with treatment for substance abuse during outpatient physician visits. Methods: Secondary data was obtained from the 1997 - 2004 National Ambulatory Medical Care Survey. Results: A substance abuse diagnosis was recorded in .9% of general and family practice visits, .8% of internal medicine visits, and 5.1% of psychiatry visits. Multivariable logistic regression found that women, elderly, non- White, and established patients were less likely to be given a substance abuse diagnosis. Conclusion: Increased screening, particularly of existing patients, may lead to decreased gender, age, and racial disparities in diagnosis and treatment.

Copyright 2007, Taylor & Francis


Barnaby B; Drummond C; McCloud A; Burns T; Omu N. Substance misuse in psychiatric inpatients: Comparison of a screening questionnaire survey with case notes. British Medical Journal 327(7418): 783-784, 2003. (5 refs.)

Doctors are poor at taking alcohol histories in many clinical settings. Given the increasing prevalence of drug misuse in the general population and in psychiatric patients, the extent of detection of drug misuse is important. We examined data to investigate the prevalence of alcohol and drug misuse in inpatients admitted to psychiatric wards and the extent and accuracy of detection by the psychiatrists doing assessments on admission. Patients who consented completed the alcohol use disorders identification test (AUDIT) and a short version of the substance abuse assessment questionnaire. Of the 200 patients who took part, 106 (53%) were men and 94 (47%) were women. Mean age was 41 years. More than half of the patients (110; 58%) reported lifetime substance misuse, and 52 (27%) reported taking illicit drugs in the 30 days before admission. Most patients (148; 74%) had no record of drug misuse in their notes. The high prevalence of substance misuse and low screening rates could have an important impact on the quality of the treatment provided. Staff in mainstream mental health services, particularly admitting psychiatrists, urgently need training in detecting and managing comorbid substance misuse.

Copyright 2003, BMJ Publishing Group


Bell L; Stargatt R; Bosanac P; Castle D; Braitberg G; Coventry N. Child and adolescent mental health problems and substance use presentations to an emergency department. Australasian Psychiatry 19(6): 521-525, 2011. (14 refs.)

Objective: The aim of this study was to determine the characteristics and referral pattern of children and adolescents with mental health problems, substance misuse and comorbidity presenting to the emergency department (ED) of a large public hospital. Method: A file audit of the ED information system was conducted over a 12 month period. Outcome measures included age, gender, diagnostic presentation, assessment, referral and disposal. Results: Forty-four substance misuse, 128 mental health and 82 comorbidity presentations were identified; 80% required treatment within 30 minutes. Few substance misuse cases were seen by mental health services and no substance misuse cases were referred for mental health service assessment. All mental health and comorbidity cases were seen by mental health services; 41% were referred to outpatient and 18% to inpatient services. Those with mental health problems displayed high levels of self-mutilation, and those with comorbidity displayed high levels of self-mutilation and substance misuse. Alcohol use was common in the substance misuse group, and over the counter or prescription medications were abused by the mental health and comorbidity groups. Conclusions: This age group places a high demand on the ED. All children and adolescents with recognized mental health symptoms were seen by mental health services, but those with substance misuse were not. Given the long-term problems associated with substance misuse, this is a missed opportunity for intervention.

Copyright 2011, Informa Healthcare


Berner MM; Harter M; Kriston L; Lohmann M; Ruf D; Lorenz G et al. Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors. Alcohol and Alcoholism 42(4): 308-316, 2007. (32 refs.)

Aims: The primary objective was to assess the proportion of detected and correctly referred patients in German primary care. The secondary objective was to identify patient and practitioner characteristics that predict detection and correct referral. Methods: In this clustered cross-sectional survey in German primary care, 3003 patients were consecutively invited to participate, and were asked to fill in a standardized health questionnaire. They were then screened for problematic alcohol consumption using the Alcohol Use Disorders Identification Test. The physicians recorded their assessment of the presence of any alcohol use disorder and documented the treatment course of all identified patients for 3 months. Results: Correctly identified problem drinkers were 38.6% in a per-protocol analysis and 33.6% using a worst-case scenario. Referral behaviour of physicians was in conformity with current practice guidelines in 64.6% of the documented cases and 27.0% in a worst-case scenario. Several patient (e.g. sex, age) and practitioner characteristics (e.g. age), which influence the diagnosis and referral of patients, could be identified. Conclusions: There is a clear need to increase the special diagnostic and therapeutic skills of general practitioners so that they may be able to indicate and perform secondary prevention. Further research should focus on the likely effects of the implementation of these diagnostic and management tools.

Copyright 2007, Oxford University Press


Boniatti MM; Diogo LP; Almeida CL; Cardoso MD. Prevalence and record of alcoholism among emergency department patients. Clinics 64(1): 29-34, 2009. (35 refs.)

OBJECTIVES: The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team. METHODS: The study population consisted of all patients admitted to the emergency room at Hospital Sao Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test. RESULTS: We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively. CONCLUSION: Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

Copyright 2009, Hospital Clinicas, Univerity of Sao Paulo


Boniatti MM; Diogo LP; Almeida CL; Cardoso MD. Prevalence and record of alcoholism among emergency department patients. Clinics 64(1): 29-34, 2009. (35 refs.)

OBJECTIVES: The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team. METHODS: The study population consisted of all patients admitted to the emergency room at Hospital Sao Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test. RESULTS: We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively. CONCLUSION: Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

Copyright 2009, Hospital Clinicas, Univerity of Sao Paulo


Boniatti MM; Diogo LP; Almeida CL; Cardoso MD. Prevalence and record of alcoholism among emergency department patients. Clinics 64(1): 29-34, 2009. (35 refs.)

OBJECTIVES: The purpose of this study was to investigate the prevalence of alcoholism among inpatients, to identify social and demographic factors associated with this prevalence and to determine its rate of recognition by the medical team. METHODS: The study population consisted of all patients admitted to the emergency room at Hospital Sao Lucas, Porto Alegre, Brazil, between July and September of 2005. The data were collected in two steps: an interview with the patient and a review of the medical records to investigate the cases of alcoholism recorded by the medical team. The questionnaire consisted of questions concerning social and demographic data, smoking habits and Alcohol Use Disorders Identification Test. RESULTS: We interviewed 248 patients. Twenty-eight (11.3%) were identified as alcoholics. Compared to the patients with a negative Alcohol Use Disorders Identification Test value (less than 8), those with a positive Alcohol Use Disorders Identification Test were more likely to be male, illiterate and smokers. The medical records of 217 (87.5%) patients were reviewed. Only 5 (20.0%) of the 25 patients with a positive Alcohol Use Disorders Identification Test whose medical records were reviewed were identified as alcoholics by the medical team. The diagnosis made by the medical team, compared to Alcohol Use Disorders Identification Test, shows only a 20% sensitivity, 93% specificity and positive and negative predictive values of 29% and 90%, respectively. CONCLUSION: Alcoholism has been underrecognized in patients who are hospitalized, and, as such, this opportunity for possible early intervention is often lost. Key social and demographic factors could provide physicians with risk factors and, when used together with a standardized diagnostic instrument, could significantly improve the rate of identification of alcoholic patients.

Copyright 2009, Hospital Clinicas, Univerity of Sao Paulo


Boyle AR; Davis H. Early screening and assessment of alcohol and substance abuse in the elderly: Clinical implications. Journal of Addictions Nursing 17(2): 95-100, 2006. (26 refs.)

The use and misuse of alcohol place older adults at risk for many detrimental physical, psychological, and social consequences that frequently go undetected. A number of risk factors have been identified in the development of alcohol-related problems, including chronic medical disorders and sleep disturbances. Social isolation, loneliness, bereavement, and the presence of experiencing acute or chronic pain are identified to increase risk for alcohol problems. Gender also has been identified as a risk factor; evidence suggests that women are more vulnerable to problems associated with alcohol than are men. A case study approach is used in this article to assist nurses in assessing and evaluating some of the major problems associated with alcohol misuse in the elderly including falls, skin trauma, insomnia, weight loss, and gastroenterological problems. The CAGE is discussed as an important instrument in assessment and evaluation of alcohol misuse.

Copyright 2006, Taylor & Francis


Bradshaw P; Denny M; Cassidy EM. Alcohol misuse in the general hospital: Some hard facts. Irish Journal of Medical Science 177(4): 339-342, 2008. (10 refs.)

To examine (1) the prevalence of alcohol use disorders in adult general hospital inpatients; (2) the accuracy of documentation in relation to alcohol use. A total of 210 random patients were interviewed out of 1,448 consecutive new admissions to CUH over 7 days. Case notes were reviewed for 206 (98%). Alcohol consumption was assessed using the Fast Alcohol Screening Test (FAST) and weekly drinking diary. FAST-positive (and a random sample of FAST-negative) patients then had a standardized interview. A total of 82% admitted for drinking alcohol. Among them 22% were drinking in excess of guidelines, 9% had DSM-IV Alcohol Abuse and 7% dependence. The sensitivity and specificity of the FAST for detecting those drinking above guidelines were 89 and 94% and for detecting a DSM-IV diagnosis was 100 and 73%. The majority of case notes contained inadequate information about alcohol intake. Alcohol use disorders are common and often undetected in the general hospital setting.

Copyright 2008, Springer


Burns L; Mattick RP. Using population data to examine the prevalence and correlates of neonatal abstinence syndrome. Drug and Alcohol Review 26(5): 487-492, 2007. (27 refs.)

The objective of this study was to determine the population prevalence and correlates of neonatal abstinence syndrome among neonates born to women on methadone, using a cross-sectional analysis of linked population health data. A total of 2941 live births to women actively on methadone at delivery were analysed over an 11-year period (1992 - 2002). Of these births, 796 neonates (27%) were diagnosed with an International Classfication of Diseases-9CM (ICD-9CM) or International Classification of Diseases ICD - 10AM (ICD-10AM) diagnosis related to neonatal withdrawal from exposure to opiates in utero (NAS). There were significant differences found between mothers whose neonates did and did not receive an International Classification of Diseases NAS-related diagnosis. Mothers of neonates with a NAS-related diagnosis had a higher number of previous pregnancies, were more likely to be indigenous, to smoke more heavily and were more likely to present for delivery unbooked. Neonates diagnosed with NAS were admitted to Special Care Nursery more often. NAS is diagnosed less frequently using International Classification of Diseases (ICD) codes than when using clinical scales measuring opiate-related neonatal withdrawal. This suggests that NAS may be under-represented in hospital morbidity databases that use ICD codes to quantify patient throughput and in some circumstances this may result from under-detection of the condition. Future research should therefore seek to determine the validity of NAS recording in hospital morbidity databases reliant on the use ICD codes.

Copyright 2007, Taylor & Francis


Cheeta S; Drummond C; Oyefeso A; Phillips T; Deluca P; Perryman K et al. Low identification of alcohol use disorders in general practice in England. Addiction 103(5): 766-773, 2008. (42 refs.)

Aims: The prevalence of alcohol use disorders (AUDs) in the United Kingdom is estimated at 25%, and primary care has been identified as the first line of treatment for this population. However, there is a paucity of evidence regarding the current rates of identification of AUDs in primary care. The aim of the present study was to compare the observed rates of AUDs in general practice with expected rates, which are based on general population prevalence rates of AUDs. Design, participants and measurements Epidemiological data on individuals aged 16-64 years with an AUD was obtained from the General Practice Research Database. General population prevalence rates of AUDs were obtained from the Psychiatric Morbidity Survey. chi(2) tests and identification ratios were used to analyse the data. Results There was a significant relationship between type of AUD and identification (chi(2) = 1466.89, P < 0.001), and general practitioners were poorer at identifying harmful/hazardous drinkers when compared with dependent drinkers. No gender differences in the identification of hazardous/harmful drinking were found, but female dependent drinkers were significantly more likely to be identified than males (identification ratio 0.07; 95% confidence interval 0.06-0.07). The identification of AUDs was significantly lower for the 16-24-year age group compared with all other age groups. Conclusion: Despite attempts at targeting hazardous/harmful drinkers for brief interventions in primary care, the present findings suggest that this group are still under-identified. Furthermore, this under-identification is even more apparent in men and in young people who have high general population prevalence rates for AUDs. In conclusion, increasing identification rates could be incorporated into brief intervention strategies in primary care.

Copyright 2008, Society for the Study of Addiction to Alcohol and Other Drugs


Chen CH; Chen WJ; Cheng ATA. Prevalence and identification of alcohol use disorders among nonpsychiatric inpatients in one general hospital. General Hospital Psychiatry 26(3): 219-225, 2004. (31 refs.)

Alcohol use disorders (AUDs) are common among inpatients in general hospitals and often cause excess mortality. This study investigates the prevalence of AUDs among nonpsychiatric inpatients in one general hospital and evaluates the ability of medical staff to identify such morbidity. A two-phase case-identification strategy was employed utilizing the Alcohol Use Disorders Identification Test as the first-phase screening tool and the Schedules for Clinical Assessment in Neuropsychiatry as the second-phase diagnostic interview. Among 538 eligible patients, a total of 422 (78.4%) completed the first-phase screening. A subsample (20%) of those screened negative and 90% of those screened positive were interviewed at the second phase. The weighted I-year prevalence rates of alcohol abuse and alcohol dependence were 3.9% and 12.6%, respectively. The overall identification rate of AUDs by medical staff was 25.4% (0% for alcohol abuse and 30% for alcohol dependence). In conclusion, approximately one sixth of nonpsychiatric inpatients in a general hospital have AUDs and have been neglected substantially by medical staff. Implications of the findings for the prevention of AUDs and their physical complications are discussed.

Copyright 2004, Elsevier Science Inc.


Coleman T; Wilson A; Barrett S; Wynne A; Lewis S. Distributing questionnaires about smoking to patients: impact on general practitioners' recording of smoking advice. BMC Health Services Research 7(e-article 153), 2007. (21 refs.)

Background: Little is known about the impact of questionnaire-based data collection methods on the consulting behaviour of general practitioners (family physicians) who participate in research. Here data collected during a research project which involved questionnaires on smoking being distributed to patients before and after appointments with general practitioners (GPs) is analyzed to investigate the impact of this data collection method on doctors' documenting of smoking advice in medical records. Methods: Researchers distributed questionnaires on smoking behaviour to 6775 patients who attended consultations during surgery sessions with 32 GPs based in Leicestershire, UK. We obtained the medical records for patients who had attended these surgery sessions and also for a comparator group, during which no researcher had been present. We compared the documenting of advice against smoking in patient's medical records for consultations within GPs' surgery sessions where questionnaires had been distributed with those which occurred when no questionnaires had been given out. Results: We obtained records for 77.9% (5276/6775) of all adult patients who attended GPs' surgery sessions, with 51.9% (2739) being from sessions during which researchers distributed questionnaires. Discussion of smoking was recorded in 8.0% (220/2739) of medical records when questionnaires were distributed versus 4.6% (116/2537) where these were not. After controlling for relevant potential confounders including patients' age, gender, the odds ratio for recording of information in the presence of questionnaire distribution (versus none) was 1.78 (95% CI, 1.36 to 2.34). Conclusion: Distributing questionnaires about smoking to patients before and after they consult with doctors significantly increases GPs' recording of discussions about smoking in medical records. This has implications for the design of some types of research into addictive behaviours and further research into how data collection methods may affect patients' and doctors' behaviours is warranted.

Copyright 2007, BioMed Central Ltd


Conigliaro J; Gordon AJ; McGinnis KA; Rabeneck L; Justice AC. How harmful is hazardous alcohol use and abuse in HIV infection: Do health care providers know who is at risk? Journal of Acquired Immune Deficiency Syndromes 33(4): 521-525, 2003. (17 refs.)

We conducted a prospective cohort study to describe the association between alcohol use, HIV disease progression, and drug toxicity and to determine health care provider awareness of excessive alcohol use by recruiting 881 HIV-infected veterans (median age, 49 years; 99% male; 54% African American) from 3 VA HIV clinics. Twenty percent of patients were hazardous drinkers by the Alcohol Use Disorders Identification Test, 33% were binge drinkers, 32% had a chart ICD-9 alcohol diagnosis, and 12.5% and 66.7%, respectively, were described by their health care providers, as currently and ever drinking "too much." Hazardous/binge drinkers more often had detectable viral loads (P < 0.001). Patients with alcohol diagnoses more often had elevated alanine transaminase or aspartate transaminase levels (P < 0.02), anemia (P < 0.001), and elevated mean corpuscular volume (P < 0.001). Health care providers missed hazardous drinking in patients with undetectable viral loads (P = 0.01), patients without hepatitis C (P = 0.09), and patients with normal aspartate transaminase levels (P = 0.07) and missed alcohol diagnoses in patients without hepatitis and those with CD4 cell counts of >200/mL. We conclude that in HIV-positive veterans, hazardous drinking and alcohol diagnoses were common and associated with HIV disease progression and/or hepatic comorbidity and anemia. Health care providers more often missed alcohol problems in patients with less severe HIV infection and those without evidence of liver disease. Health care providers should routinely screen and counsel patients regarding alcohol problems as part of standard of care to minimize disease progression and bone marrow and hepatic toxicity.

Copyright 2003, Lippincott-Raven Publications


Degenhardt L; Knox S; Barker B; Britt H; Shakeshaft A. The management of alcohol, tobacco and illicit drug use problems by general practitioners in Australia. Drug and Alcohol Review 24(6): 499-506, 2005. (30 refs.)

The aim of this study was to document the frequency of the management of illicit drug, alcohol and tobacco problems in general practice in Australia. Data from the Bettering the Evaluation and Care of Health (BEACH) study of general practice, April 1998 to March 2003, were analysed. BEACH is an ongoing national study of general practice in Australia. Each year a random sample of approximately 1000 general practitioners (GPs) participate, each providing details of 100 patient encounters. Samples are drawn from the Medicare data held by the Health Insurance Commission. Patient demographic breakdowns, medication, other treatment, referrals and other medical procedures ordered were examined for all problems labelled by GPs as illicit, alcohol and tobacco problems. Annually in Australia, it was estimated that 615 000 GP encounters - or 0.6% of all encounters - involved the management of illicit drug use problems presumably most commonly for problematic heroin use. Despite a much higher population prevalence of use and use disorders, the management of alcohol or tobacco use problems was less common, with 0.4% and 0.3% of encounters, respectively, comprising treatment of these problems. Clear demographic differences existed across the groups. The management of problems also differed, with illicit drug use problems more likely to involve provision of medication, and alcohol and tobacco treatment more likely to involve counselling and/ or health advice. Despite higher rates of alcohol and tobacco use problems among patients seeing GPs in Australia, the rate of treatment for such problems was relatively lower than it was for illicit drug use problems. More efforts need to be directed towards assisting GPs to identify and target problematic alcohol and tobacco use among their patients.

Copyright 2005, Taylor and Francis, Ltd.


Dermengiu D; Radu D; Aciu F; Broscauceanu A; Sereteanu L; Gorun G et al. Drugs of abuse identified in the National Institute of Legal Medicine Mina Minovici Bucharest 2010. Romanian Journal of Legal Medicine 19(3): 229-232, 2011. (10 refs.)

In the last few years in Romania a modern system of drug detection has been developed in the legal medicine system, increasing the detection rate and the sensitivity of DRD detection. In this short report we will present a general profile of drug abuse in Bucharest in 2010. The study was conducted in 2010 when a total number of 208 toxicology tests were conducted in the National Institute of Legal Medicine, 105 on cadavers and 103 on living persons. As main results, in living the most frequently identified drugs of abuse were THC and opiates whilst in cadavers opiates were the most frequent, followed by benzodiazepines. Conclusions. Opiate consumption has a tendency to decrease compared with 2009. Legal highs seems to shift the pattern of drug consumption in Bucharest and surrounding areas, but a definite results can only be obtained using test results from 2011.

Copyright 2011, Romanian Legal Medicine Society


Desai S; Aldea D; Daneels E; Soliman M; Braksmajer AS; Kopes-Kerr CP. Chronic addiction to dextromethorphan cough syrup: A case report. Journal of the American Board of Family Medicine 19(3): 320-323, 2006. (12 refs.)

Background: Serious drug abuse and addiction related to dextromethorphan-containing cough preparations has been a problem in the United States since the 1950s, but few physicians are aware of it. Physicians must be alert to the type of substances and quantities used and misused by patients in obtaining a thorough routine history of over-the-counter medication use. Methods: We describe the case of a 66-year-old clerical worker who ingested 4 to 16 oz of dextromethorphan on a regular basis over an 8-year period. We consulted with our local Poison Control Center and undertook a literature search to research previous reports of similar cases to identify the features that would aid physicians in recognition and management of this problem. Results and Conclusion: Despite the availability of a substantial number of case reports in specialty journals, there are almost no reports in the primary care literature of chronic dextromethorphan addiction. Our case highlights the difficulties in making an appropriate diagnosis and in obtaining effective help for the patient.

Copyright 2006, American Board of Family Medicine


Edlund MJ; Unutzer A; Wells KB. Clinician screening and treatment of alcohol, drug, and mental problems in primary care: Results from Healthcare for Communities. Medical Care 42(12): 1158-1166, 2004. (50 refs.)

Objective: We sought to estimate national rates of screening and treatment of alcohol, drug, and mental (ADM) problems in primary care. Design: This was a cross-sectional survey administered from 1997 to 1998. Participants: Our study included a nationally representative household probability sample of 7301 primary care patients. Measurement: We used patient self-reports from a telephone survey to estimate rates of screening and treatment of common ADM problems, to examine the types of screening and treatment received, and to investigate adherence with treatment recommendations. Covariates included measures of ADM conditions, physical health, and sociodemographic indicators. Results: Among adult primary care patients, 38.6% (95% confidence intervals [CI] 37.2-40.0) reported clinician screening for an ADM problem. Alcohol or drug screening occurred more frequently (28.3%; 95% CI 27.0-29.6) than screening for depression and anxiety (21.2%; 95% CI 20.1-22.2). Among those screened, 30.1% (95% CI; 27.8-32.4) reported ADM treatment in primary care. Medications (16.4%; 95% CI 14.3-18.5) and counseling (18.2%; 95% CI 16.1-20.3) were the most common treatments. Rates of screening were higher among individuals with ADM disorders, the young and middle aged, and the college educated. Treatment rates were higher among individuals with ADM disorders. Conclusions: Substantial effort is expended screening and treating common ADM problems in primary care, and these efforts are targeted towards those with ADM disorders. However, only about half of individuals with an ADM disorder report being screened, and among this group, about 60% report receiving any treatment.

Copyright 2004, Lippincott, Williams & Wilkins


Elliott EJ; Payne J; Haan E; Bower C. Diagnosis of foetal alcohol syndrome and alcohol use in pregnancy: A survey of paediatricians' knowledge, attitudes and practice. Journal of Paediatrics and Child Health 42(11): 698-703, 2006. (29 refs.)

Aim: To measure paediatricians' knowledge, attitudes and practices regarding foetal alcohol syndrome (FAS) and alcohol use during pregnancy. Methods: Postal survey of paediatricians in Western Australia in 2004. Of 179 eligible paediatricians, 132 (73.7%) responded (90 consultant paediatricians and 42 paediatric trainees). Results: Of the 132 respondents, 18.9% identified all four essential diagnostic features for FAS. Only 49.2% had previously diagnosed FAS (range 1-30 cases) but 91.7% had seen children diagnosed by others; 76.5% had suspected but not diagnosed FAS; 12.1% had been convinced of but not recorded the diagnosis; and 31.8% had referred children for diagnostic confirmation. Although 79.6% agreed early diagnosis might be advantageous, 69.6% said diagnosis might be stigmatising and 36.4% thought parents might resist referral for assessment and treatment. Although 78.2% agreed avoiding binge drinking may reduce FAS, only 43.9% believed women should abstain from using alcohol in pregnancy. Only 4.5% felt very prepared to deal with a patient with FAS: most wanted educational materials for themselves (69.7%) and child carers (71.2%). Only 23.3% routinely ask about alcohol use when taking a pregnancy history and 4.2% routinely provide information on the consequences of alcohol use. Only 11.4% had read the current Australian National Health Guideline regarding alcohol consumption in pregnancy and 9.1% provided advice consistent with the guideline. Conclusion: Paediatricians identified the need for educational materials about FAS and alcohol use in pregnancy for themselves and their clients. Lack of knowledge about FAS diagnosis and management will limit opportunities for diagnosis, prevention and early intervention.

Copyright 2006, Blackwell Publishing


Ferguson L; Ries R; Russo J. Barriers to identification and treatment of hazardous drinkers as assessed by urban/rural primary care doctors. Journal of Addictive Diseases 22(2): 79-90, 2003. (35 refs.)

This pilot study analyzed three types of barriers encountered by forty family physicians when identifying and treating patients with hazardous drinking and alcohol dependence. The Patient Centered category included patient denial and lack of motivation to change. The Physician Centered category included lack of physician time and lack of addiction medicine training. The System Centered category included lack of community resources and distance to treatment programs. The Patient Centered barriers were rated significantly greater (p <.001) than the Physician Centered or the System Centered barriers. There was also a significant negative correlation (r = -0.49, p <.001) between the Physician Centered and the Patient Centered categories, meaning that the more problematic the patients were rated, the less problematic the physicians rated their time or training. The types of barriers that were rated as most problematic varied depending on rural/urban practice location and how current the physician's training was.

Copyright 2003, The Haworth Press, Inc.


Freimuth M. Another missed opportunity? Recognition of alcohol use problems by mental health providers. Psychotherapy 45(3): 405-409, 2008. (16 refs.)

Alcohol use problems (AUPs) are prevalent among people seeking psychotherapy. Despite mandates from managed care companies to routinely screen for AUPs, little is known about the screening practices of providers or their ability to identify AUPs based on presenting symptoms. Participants (N = 117) read two case vignettes and suggested initial diagnoses and questions they would ask in order to clarify a diagnosis. Participants were more likely to ask about substance use and diagnose an AUP when the vignette contained explicit reference to the client's substance use as compared to a vignette where the signs of an A UP were more subtle. In both vignettes, a mental health problem was a more likely diagnosis than an AUP. Neither participant attributes nor personal or professional experiences with AUPs reliably shaped responses to the vignettes. The findings are discussed in light of their implications for future research and improved training in addictions for mental health providers.

Copyright 2008, American Psychological Association


Freithmuth M. Hidden Addictions: Assessment Practices for Psychotherapists, Counselors, and Health Care Providers. Lanhan: Jason Aronson, 2005

This book is directed to identification and assessment for addiction within the psychotherapy context. Media portrayals and diagnostic criteria convey an image of an addicted person as those whose deficient coping skills and severely compromised functioning are readily apparent. Yet addictions remain some of the most frequently missed diagnoses in health and mental health care settings. In the context of psychotherapy, the typical patient with an addiction will present depression, anxiety, marital problems or a general sense that life is not working. This book addresses how addictions can be recognized more often and accurately assessed. Beyond presenting the standard assessment instruments, there is consideration of clinical tools for asking the appropriate questions and listening to the clinical dialogue for signs of a undisclosed addiction. Individual chapters are directed to impediments to accurate assessment, assessment, applications with special populations, clinical skills in assessment, and transforming the assessment process into treatment. Illustrative case studies are provided.

Copyright 2005, Jason Aronson


Gassman RA; Weisner C. Community providers' views of alcohol problems and drug problems. Journal of Social Work Practice in the Addictions 5(4): 101-115, 2005. (53 refs.)

This study contrasts community health and social service providers' views on alcohol vs. other drug abuse. A probability sample of 457 social work and other providers from a county's public and private medical and mental health clinics, welfare and criminal justice systems, and substance abuse programs, as well as clergy, private therapists, and physicians were interviewed. For both alcohol and drug problems, providers thought only of severe dysfunctions, which suggest that less severe forms of these problems may evade detection. In addition, drug problems were viewed as more harmful than alcohol problems, which may result in providers minimizing alcohol problems.

Copyright 2005, Haworth Press


Goldstein BI; Bukstein OG. Comorbid substance use disorders among youth with bipolar disorder: Opportunities for early identification and prevention. Journal of Clinical Psychiatry 71(3): 348-358, 2010. (92 refs.)

Objective: The burden of substance use disorders (SUDs) among adults with bipolar disorder is well documented. Comparatively less is known regarding comorbid SUD among youth with bipolar disorder. This article aims to integrate the extant literature on this topic and to suggest strategies for delaying or preventing SUD among youth with bipolar disorder. Data Sources and Study Selection: Relevant studies in English were identified using Pub Med and MEDL1NE (1950-February 2009). Search terms were bipolar disorder cross-referenced with child, adolescent, or youth, and alcohol, drug, or substance, and abuse, dependence, or disorder. Articles were selected on the basis of containing data regarding both bipolar disorder and SUD. The search was supplemented by manually reviewing reference lists from the identified publications. Data Synthesis: Epidemiologic and clinical studies demonstrate that youth-onset bipolar disorder confers even greater risk of SUD in comparison with adultonset bipolar disorder. Recent studies of youth with bipolar disorder have not identified childhood SUD (0%); however, the prevalence of SUD escalates during adolescence (I6%-39%). Substance use disorder among bipolar youth is associated with legal and academic difficulties, pregnancy, and suicidality. Few studies have addressed interventions for this population, although studies are underway. Because bipolar disorder onset most commonly precedes SUD among youth (55%-83%), there is a window of opportunity for prevention. Conclusions: Pending the results of ongoing treatment studies, several strategies are suggested for curtailing the burden of SUD in youth with bipolar disorder. These include screening for substance use among bipolar youth beginning at age 10 irrespective of other risk factors, education and intervention at the family level, and implementation of preventive interventions that have been successful in other populations.

Copyright 2010, Physicians Postgraduate Press


Goldstein BI; Bukstein OG. Comorbid substance use disorders among youth with bipolar disorder: Opportunities for early identification and prevention. Journal of Clinical Psychiatry 71(3): 348-358, 2010. (92 refs.)

Objective: The burden of substance use disorders (SUDs) among adults with bipolar disorder is well documented. Comparatively less is known regarding comorbid SUD among youth with bipolar disorder. This article aims to integrate the extant literature on this topic and to suggest strategies for delaying or preventing SUD among youth with bipolar disorder. Data Sources and Study Selection: Relevant studies in English were identified using Pub Med and MEDL1NE (1950-February 2009). Search terms were bipolar disorder cross-referenced with child, adolescent, or youth, and alcohol, drug, or substance, and abuse, dependence, or disorder. Articles were selected on the basis of containing data regarding both bipolar disorder and SUD. The search was supplemented by manually reviewing reference lists from the identified publications. Data Synthesis: Epidemiologic and clinical studies demonstrate that youth-onset bipolar disorder confers even greater risk of SUD in comparison with adultonset bipolar disorder. Recent studies of youth with bipolar disorder have not identified childhood SUD (0%); however, the prevalence of SUD escalates during adolescence (I6%-39%). Substance use disorder among bipolar youth is associated with legal and academic difficulties, pregnancy, and suicidality. Few studies have addressed interventions for this population, although studies are underway. Because bipolar disorder onset most commonly precedes SUD among youth (55%-83%), there is a window of opportunity for prevention. Conclusions: Pending the results of ongoing treatment studies, several strategies are suggested for curtailing the burden of SUD in youth with bipolar disorder. These include screening for substance use among bipolar youth beginning at age 10 irrespective of other risk factors, education and intervention at the family level, and implementation of preventive interventions that have been successful in other populations.

Copyright 2010, Physicians Postgraduate Press


Goransson M; Magnusson A; Heilig M. Identifying hazardous alcohol consumption during pregnancy: Implementing a research-based model in real life. Acta Obstetricia et Gynecologica Scandinavica 85(6): 657-662, 2006. (31 refs.)

Aims. It has been repeatedly demonstrated that hazardous alcohol use during pregnancy is rarely detected in regular antenatal care, and that detection can be markedly improved using systematic screening. A major challenge is to translate research-based strategies into regular antenatal care. Here, we examined whether a screening strategy using the Alcohol Use Disorder Test (AUDIT) and time-line follow-back (TLFB) could be implemented under naturalistic conditions and within available resources, and whether it would improve detection to the extent previously shown in a research context. Methods. Regular midwives at a large antenatal care clinic were randomized to receive brief training and then implement AUDIT and TLFB ("intervention"); or to a waiting-list control group continuing to deliver regular care ("control"). In the intervention condition, AUDIT was used to collect data about alcohol use during the year preceding pregnancy, and TLFB to assess actual consumption during the first trimester. Data were collected from new admissions over 6 months. Results. Drop out was higher among patients of the intervention group than control midwives, 14% (23/162) versus 0% (0/153), and p < 0.0001. A one-day training session combined with continuous expert support was sufficient to implement systematic screening with AUDIT and TLFB largely within resources of regular antenatal care. The use of these instruments identified patients with hazardous consumption during the year preceding pregnancy i.e. AUDIT score 6 or higher (17%, 23/139), and patients with ongoing consumption exceeding 70 g/week and/or binge consumption according to TLFB (17%, 24/139), to a significantly higher degree than regular antenatal screening (0/162). The AUDIT- and TLFB-positive populations overlapped partially, with 36/139 subjects screening positive with either of the instrument and 11/139 were positive for both. Conclusions. We confirm previous findings that alcohol use during pregnancy is more extensive in Sweden than has generally been realized. Systematic screening using AUDIT and TLFB detects hazardous use in a manner which regular antenatal care does not. This remains true under naturalistic conditions, following minimal training of regular antenatal care staff, and can be achieved with minimal resources. The proposed strategy appears attractive for broad implementation.

Copyright 2006, Munksgaard Int. Publ, Ltd.}


Green AI; Canuso CM; Brenner MJ; Wojcik JD. Detection and management of comorbidity in patients with schizophrenia. (review). Psychiatric Clinics of North America 26(1): 115+, 2003. (216 refs.)

Approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition, worsening prognosis and contributing to the high rate of morbidity and mortality. Depression is associated with suicide, the leading cause of premature death in patients with schizophrenia; obsessive-compulsive symptoms may worsen prognosis; alcohol and substance use disorders are associated with a poor outcome; and comorbid medical conditions, including cardiac and pulmonary disease, infectious diseases, diabetes, hyperlipidemia, hypogonadism, and osteoporosis, are often underrecognized and undertreated. The new generation of antipsychotic medications has improved the potential outcome of patients with schizophrenia. Providing optimal treatment for patients and fully realizing the potential of these new agents require focused attention on detection, recognition, and treatment of comorbid psychiatric and medical conditions in patients with schizophrenia.

Copyright 2003, W.B. Saunders Co.


Griffiths RD; Stone A; Trani DT; Fernandez RS; Ford K. Drink a little; take a few drugs: Do nurses have knowledge to identify and manage in-patients at risk of drugs and alcohol? Drug and Alcohol Review 26(5): 545-552, 2007. (25 refs.)

Introduction and Aims. The widespread use of alcohol and other drugs poses particular problems during hospitalisation. Although nurses have been identified as an appropriate group to screen patients and provide acute and ongoing management to people with drug and alcohol-related problems, rates of screening are low. The aims of this study were to identify current practices for screening by nurses working in medical and surgical wards, determine their knowledge relating to problems associated with substance use and identify their self-reported skills in managing patients with drug- and alcohol-related problems. Design and Methods. A chart audit of medical records was completed and a survey was distributed to nurses working in the study wards. Results. Screening for alcohol and drug use was documented on only 22179 medical records, and detailed information about quantity and duration of use was recorded in only nine. Overall, the nurses reported that they had little knowledge about substance use problems, and felt that they lacked skills to care adequately for these patients. Discussion and Conclusions. The results of this study suggest a need for a comprehensive training and education to ensure that nurses are familiar with policies and protocols for management of patients and to assist nurses to provide evidence-based care and make appropriate referrals to specialist services.

Copyright 2007, Taylor & Francis


Gual A; Sabadini MBD. Implementing alcohol disorders treatment throughout the community. (review). Current Opinion in Psychiatry 24(3): 203-207, 2011. (35 refs.)

Purpose of review: Alcohol is the world's third leading cause of ill-health and premature death. Alcohol has been found to be the most harmful drug, when considering harm to the individual and to others. With a prespecified search strategy we looked for relevant articles concerning screening, brief interventions and referral to treatment of patients with hazardous or harmful alcohol use, with a special focus on the primary healthcare implementation of these effective interventions. Recent findings: The evidence on the efficacy and effectiveness of brief interventions in primary care continues to grow and is confirmed by many recent studies, even in specific populations. The implementation of those effective interventions continues to be difficult, but successful experiences have been reported. The use of brief interventions in other healthcare settings and to address problems other than risky drinking is promising, but the evidence is far from conclusive. Some specific age groups (elderly, women and youth below 16) may deserve specifically tailored interventions. Summary: Alcohol is a major public health problem and brief interventions are one of the cost-effective measures that can be taken at a community level. Nevertheless, implementation of those measures is difficult. Further research is needed to identify the best implementation strategies.

Copyright 2011, Lippincott, Williams & Wilkins


Gunderson EW; Levin FR; Smith L. Screening and intervention for alcohol and illicit drug abuse: A survey of internal medicine housestaff. Journal of Addictive Diseases 24(2): 1-18, 2005. (51 refs.)

This study attempts to determine how internal medicine housestaff screen and intervene for problematic alcohol and illicit drug use, as well as identify factors correlating with favorable practices. A cross-sectional survey was administered to 93 medical housestaff. Of 64 (69%) respondents, 94% reported routinely screening new patients for alcohol or illicit drug use, while only 52% routinely quantified alcohol consumption and 28% routinely used a screening instrument. Housestaff were unfamiliar with national guidelines and felt unprepared to diagnose substance use disorders, particularly prescription drug abuse. Most routinely counseled patients with alcohol (89%) or illicit-drug problems (91 %), although only a third of these patients were referred for formal treatment. More thorough screening practices were associated with greater treatment optimism, while favorable referral practices were associated with greater optimism about 12-step program benefit and difficulty with management. These findings suggest areas to be addressed in residency curricula on substance abuse.

Copyright 2005, Haworth Press Inc.


Hawkins EJ; Kivlahan DR; Williams EC; Wright SM; Craig T; Bradley KA. Examining quality issues in alcohol misuse screening. Substance Abuse 28(3): 53-65, 2007

The Veterans Health Administration (VHA) has successfully implemented evidence-based alcohol misuse screening with the AUDIT-C. The purpose of this study was to evaluate clinical alcohol screening during the first year after implementation. Using medical record review and mailed patient surveys collected during 2004 by VHA Office of Quality and Performance, this study analyzed concordance of screening results among patients with AUDIT-Cs in both data sources. Among 1,637 patients with AUDIT-C from both sources within 90 days, the medical record screening prevalence rate of alcohol misuse, 24.6% (95% CI: 22.5% to 26.7%), was significantly lower than the survey rate, 33.4% (31.1% to 35.7%). Of 8,312 patients identified as nondrinkers in medical records, 24% reported past year alcohol use and 5% screened positive for alcohol misuse on surveys. Lower rates of alcohol use and misuse documented in medical records compared to mailed surveys suggest further investigation and standardization of clinical screening are necessary.

Copyright 2007, Association for Medical Education & Research in Substance Abuse


Haynes CL; Cook GA. Audit of health promotion practice within a UK hospital: Results of a pilot study. Journal of Evaluation in Clinical Practice 14(1): 103-109, 2008. (17 refs.)

Introduction and aim There is clear evidence that modifiable risk factors - smoking, alcohol misuse, poor diet, lack of exercise and obesity - are detrimental to health. UK public health policy now requires hospitals to have in-place health promotion programmes to empower patients to swap risky for healthy behaviours. This audit aimed to determine a baseline level of health promotion practice for modifiable risk factors in a UK hospital. Method Case notes from two hundred and fifty hospitalized adult patients (excluding all terminally ill patients), discharged alive between January and June 2004, were audited for evidence of screening for risk factors (smoking, alcohol, diet, exercise and obesity) and the provision of health promotion to change these risk behaviours. Results The majority of inpatients were asked about smoking (88%) and alcohol consumption (74%), but few were screened for obesity (18%) or asked about their normal diet (5%) and physical activity (3%). Health promotion was delivered to a third of smokers and over half of inpatients reporting misuse of alcohol. Healthy diets, exercise and weight management were rarely discussed. Only three inpatients were screened for all risk factors. Conclusion This study indicates that the majority of hospital inpatients were screened for smoking and alcohol use, but improvements need to be made in the delivery of health promotion for smoking cessation and sensible drinking. It is clear that inpatients' are not routinely screened for diet, exercise and weight status, nor delivered health promotion for the management of these risk behaviours.

Copyright 2008, Blackwell Publishing


Hill KP; Chang G. Brief screening instruments for risky drinking in the outpatient psychiatry clinic. American Journal on Addictions 16(3): 222-226, 2007. (33 refs.)

In this pilot study, we compared two brief screening instruments, the T-ACE ( Tolerance, Annoyed, Cut down, Eye-opener) and the Alcohol Use Disorders Identification Test (AUDIT), with a clinician interview and structured clinical interview (SCID) to determine if they improved identification of risky drinking in a psychiatry clinic compared to clinician interviews. Sixteen of 50 subjects satisfied DSM-IV criteria for lifetime alcohol abuse or dependence on the SCID, and four, all T-ACE positive, were listed "correctly'' in the chart as having an alcohol problem. With a SCID gold standard, risky drinking was identified with sensitivities and specificities of 0.88 and 0.59 for the T-ACE and 0.63 and 0.85 for the AUDIT. Brief screening instruments improved the identification of risky drinking in a psychiatry clinic.

Copyright 2007, Taylor & Francis


Hoch E; Muehlig S; Hofler M; Lieb R; Wittchen HU. How prevalent is smoking and nicotine dependence in primary care in Germany? Addiction 99(12): 1586-1598, 2004. (48 refs.)

Aims: Identifying, diagnosing and reducing nicotine use, dependence and related morbidity are considered key responsibilities of primary care physicians. Little is known, however, about the magnitude of the problem in primary care and the extent of treatment in Germany. This paper reports on (1) life-time and point prevalences of smoking and nicotine dependence among unselected consecutive German primary care attendees; (2) associations of smoking status with socio-demographic features and (3) rates of doctors' recognition and treatment patterns. Design: Data came from the Smoking and Nicotine Dependence Awareness and Screening Study (SNICAS), a nationally representative two-stage epidemiological point prevalence study (stage I: prestudy characterization of a nation-wide sample of 889 primary care doctors; stage II: target day assessment of 28 707 unselected consecutive patients). Results: (1) Of all primary care attendees, 71% reported having ever used a tobacco product (life-time regular smokers 51%; life-time occasional smokers 21.5%.). Point prevalence (4 weeks) of smoking was considerably lower (occasional use 4.7%, regular use 24.9%). The rate of DSM-IV nicotine dependence (13.9%) was highest among the youngest age groups. (2) Rates of regular and dependent smokers decreased markedly with age, mainly as a result of the steadily increasing numbers of male ex-smokers and low numbers of older female life-time ever smokers. Young age, unemployment, being single, divorced, widowed or separated from the partner were associated with higher rates of smoking or nicotine dependence. (3) In about 25% of patients, primary care doctors failed to recognize the patient's current smoking and/or nicotine dependence. Case recognition was highest for nicotine dependence (76%). Among recognized cases, 56% had ever received any kind of advice or counselling about quitting; yet only 12% had ever participated in any smoking cessation programme. Conclusions: Beyond the confirmation of the well-established finding of a high prevalence of smokers in primary care, this paper demonstrates (1) considerable point prevalence of DSM-IV nicotine dependence (14%); (2) that it is noteworthy, however, that the rates are not higher than those in community samples; and (3) a considerable variation by age group with highest rates among the young (22-31%), but considerably lower rates among subjects aged 50 and above (16% to 0.9% in the oldest). This substantial association with age seems to be due mainly to the low smoking rates in older women and the increasing numbers of successful, particularly male, quitters from 40 years onwards. Recognition of primary care patients' smoking status by primary-care practitioners was moderate, and the frequency of past and current primary care interventions was low. These findings call for systematic investigation into barriers that impede the implementation of smoking cessation interventions in primary care settings.

Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs


Holloway AS; Watson HE; Arthur AJ; Starr G; McFadyen AK; McIntosh J. The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting. Addiction 102(11): 1762-1770, 2007. (43 refs.)

Aims (i) To evaluate the effect of receiving one of two brief interventions in reducing alcohol consumption among general hospital patients compared with usual care. (ii) To assess whether a brief intervention of self-efficacy enhancement was superior to a self-help booklet in reducing alcohol consumption. Design A three-arm cluster randomized controlled trial. Setting: Seven general medical, six general surgical, one dermatology and two otolaryngology wards of a large teaching hospital covering a large urban and rural area. Participants: A total of 215 of 789 in-patients aged 18-75 years, who screened positive for alcohol consumption in excess of national recommended limits according to a 7-day retrospective drinking diary. Interventions Participants were allocated to receive one of three interventions: (i) face-to-face self-efficacy enhancement; (ii) a self-help booklet; or (iii) usual care. Measurements: The primary outcome measure was change in reported alcohol consumption at 6-month follow-up as measured by a 7-day retrospective drinking diary. Secondary outcomes were change in: number of alcohol drinking days in last week; the maximum units of alcohol consumed on any one day in last week; and Drinking Refusal Self-efficacy Expectancy Questionnaire score. Findings: Compared to the usual care group the self-efficacy enhancement group (-10.1 units 95% CI -16.1 to -4.1) and the self-help booklet group (-10.0 units 95% CI -16.0 to -3.9) had greater reductions in self-reported weekly alcohol consumption. There was no evidence that self-efficacy enhancement was superior to the self-help booklet (P = 0.96). Conclusions: Brief interventions delivered in hospital offer simple means of helping heavy drinkers to reduce their alcohol consumption.

Copyright 2007, Society for the Study of Addiction to Alcohol and Other Drugs


Hu HM; Kline A; Huang FY; Ziedonis DM. Detection of co-occurring mental illness among adult patients in the New Jersey substance abuse treatment system. American Journal of Public Health 96(10): 1785-1793, 2006. (44 refs.)

Objectives. We assessed the detection of mental illness in an adult population of substance abuse patients and the rate of referral for mental health treatment. Methods. We obtained combined administrative records from 1994 to 1997 provided by the New Jersey substance abuse and mental health systems and estimated detection and referral rates of patients with co-occurring disorders (n=47379). Mental illness was considered detected if a diagnosis was in the record and considered undetected if a diagnosis was not in the record but the patient was seen in both treatment systems within the same 12-month period. Predictors of detection and referral were identified. Results. The detection rate of co-occurring mental illness was 21.9% (n = 10364); 57.9% (n=6001) of these individuals were referred for mental health treatment. Methadone maintenance clinics had the lowest detection rate but the highest referral rate. Male, Hispanic, and African American patients, as well as those who used heroin or were in the criminal justice system, had a higher risk of mental illness not being detected. Once detected, African American patients, heroin users, and patients in the criminal justice system were less likely to be referred for treatment. Conclusions. There is a need to improve the detection of mental illness among substance abuse patients and to provide integrated treatment.

Copyright 2006, American Public Health Association


Hunt M; Kouimtsidis C; Reynolds M; Lind J; Ghodse H. Smoking among patients admitted to a general hospital: A missed opportunity for early intervention. Drugs: Education, Prevention and Policy 10(1): 31-38, 2003. (14 refs.)

The aim of this study was to estimate the prevalence of smoking within the general hospital population and to explore strategies for early intervention. This is a prospective questionnaire survey and case note review. The data reported in this paper are part of a larger study. The participants were all patients aged 18 and over admitted over a 1 week period in late March 2000 to a large London teaching hospital. The measurements made were demographic data, a lifestyle questionnaire, a smoking questionnaire, a smoking interview and case note review. The findings were as follows. The majority (47%) of the people were categorized as 'ex-smokers'. 30% of people had never smoked and 23% were categorized as 'current smokers'. Significantly fewer smokers were exercising or careful with their diet. Only 60% of patients were screened for smoking by the hospital team. The majority of smokers would like to stop smoking. There were more ex-smokers in the inpatient population than in the general population. These findings suggest that inpatient stay could offer the opportunity for the promotion of a healthy lifestyle as well as more specific early interventions.

Copyright 2003, Carfax Publishing Co.


Indig D; Copeland J; Conigrave KM; Arcuri A. Characteristics and comorbidity of drug and alcohol-related emergency department presentations detected by nursing triage text. Addiction 105(5): 897-906, 2010. (30 refs.)

Introduction: This study used nursing triage text to detect drug- and alcohol-related emergency department (ED) presentations and describe their patient and service delivery characteristics. Methods: Data were reviewed for all ED presentations from 2004 to 2006 (n = 263 937) from two hospitals in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for more than 100 drug-related and more than 60 alcohol-related terms. Adjusted odds ratios were used to compare the characteristics of drug and alcohol-related ED presentations with all other ED presentation types. Results: Just over 5% of ED presentations were identified as alcohol-related and 2% as drug-related. The most prevalent drug-related ED presentations specified were related to amphetamines (18%), heroin (14%), cannabis (14%) and ecstasy (12%), while nearly half (43%) were drug unspecified. Polydrug use was mentioned in 25% of drug-related and 9% of alcohol-related ED presentations, with the highest rate of polydrug use among ecstasy-related (68%) presentations. Drug- and alcohol-related ED presentations were significantly more likely than other ED presentations to have a mental health diagnosis, with the highest rates found among cannabis-related (OR = 7.6) or amphetamine-related (OR = 7.5) presentations. Conclusion: The ED provides an opportunity for early intervention for patients presenting with comorbid drug and alcohol and mental health problems. Further research is needed to assess the prevalence of drug and alcohol problems in ED patients with mental health problems and to develop effective interventions in that setting.

Copyright 2010, Society for the Study of Addiction to Alcohol and Other Drugs


Indig D; Copeland J; Conigrave KM; Arcuri A. Characteristics and comorbidity of drug and alcohol-related emergency department presentations detected by nursing triage text. Addiction 105(5): 897-906, 2010. (30 refs.)

Introduction: This study used nursing triage text to detect drug- and alcohol-related emergency department (ED) presentations and describe their patient and service delivery characteristics. Methods: Data were reviewed for all ED presentations from 2004 to 2006 (n = 263 937) from two hospitals in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for more than 100 drug-related and more than 60 alcohol-related terms. Adjusted odds ratios were used to compare the characteristics of drug and alcohol-related ED presentations with all other ED presentation types. Results: Just over 5% of ED presentations were identified as alcohol-related and 2% as drug-related. The most prevalent drug-related ED presentations specified were related to amphetamines (18%), heroin (14%), cannabis (14%) and ecstasy (12%), while nearly half (43%) were drug unspecified. Polydrug use was mentioned in 25% of drug-related and 9% of alcohol-related ED presentations, with the highest rate of polydrug use among ecstasy-related (68%) presentations. Drug- and alcohol-related ED presentations were significantly more likely than other ED presentations to have a mental health diagnosis, with the highest rates found among cannabis-related (OR = 7.6) or amphetamine-related (OR = 7.5) presentations. Conclusion: The ED provides an opportunity for early intervention for patients presenting with comorbid drug and alcohol and mental health problems. Further research is needed to assess the prevalence of drug and alcohol problems in ED patients with mental health problems and to develop effective interventions in that setting.

Copyright 2010, Society for the Study of Addiction to Alcohol and Other Drugs


Indig D; Copeland J; Conigrave KM; Rotenko I. Why are alcohol-related emergency department presentations under-detected? An exploratory study using nursing triage text. Drug and Alcohol Review 27(6): 584-590, 2008. (45 refs.)

Introduction and Aims. This study examined two methods of detecting alcohol-related emergency department (ED) presentations, provisional medical diagnosis and nursing triage text, and compared patient and service delivery characteristics to determine which patients are being missed from formal diagnosis in order to explore why alcohol-related ED presentations are under-detected. Design and Methods. Data were reviewed for all ED presentations from 2004 to 2006 (n=118 881) for a major teaching hospital in Sydney, Australia. Each record included two nursing triage free-text fields, which were searched for over 60 alcohol-related terms and coded for a range of issues. Adjusted odds ratios were used to compare diagnostically coded alcohol-related presentations to those detected using triage text. Results. Approximately 4.5% of ED presentations were identified as alcohol-related, with 24% of these identified through diagnostic codes and the remainder identified by triage text. Diagnostic coding was more likely if the patient arrived by ambulance [odds ratio (OR)=2.35] or showed signs of aggression (OR=1.86). Failure to code alcohol-related issues was more than three times (OR=3.23) more likely for patients with injuries. Discussion and Conclusions. Alcohol-related presentations place a high demand on ED staff and less than one-quarter have an alcohol-related diagnosis recorded by their treating doctor. In order for routine ED data to be more effective for detecting alcohol-related ED presentations, it is recommended that additional resources such as an alcohol health worker be employed in Australian hospitals. These workers can educate and support ED staff to identify more clearly and record the clinical signs of alcohol and directly provide brief interventions.

Copyright 2008, Taylor & Francis


Jewell CE; Tomlinson J; Weaver M. Identification and management of prescription opioid abuse in hospitalized patients. Journal of Addictions Nursing 22(1-2): 32-38, 2011. (51 refs.)

Prescribing of opioids for acute and chronic pain has increased; so has the incidence of abuse of these medications. Patients in the hospital may have hyperalgesia, tolerance, and dependence on opioids which can complicate their overall treatment. Some patients have opioid addiction from prescription opioids as well as heroin with aberrant medicine taking behaviors. Managing these patients takes special knowledge and skills from the whole team. It is important to identify patient concerns and barriers to treatment and work as a team to treat the pain with pharmacological, nonpharmacological, and behavioral techniques to help keep the patient safe and comfortable during their hospitalization. A nonjudgmental attitude and problem-solving approach are necessary for medical (pain) and psychosocial issues. Recommendations for safe prescribing of opioids to the addicted patient at discharge are included.

Copyright 2011, Informa Healthcare


Kennedy C; Finkelstein N; Hutchins E; Mahoney J. Improving screening for alcohol use during pregnancy: The Massachusetts ASAP program. Maternal and Child Health Journal 8(3): 137-147, 2004. (41 refs.)

Objective: To motivate prenatal care staff in public and private settings to universally screen of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit. Methods: The ASAP Projects methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital. Results: Across 16 sites 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit. Conclusions: Screening and visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.

Copyright 2004, Springer/Plenum


Knauer C. Geriatric alcohol abuse: A national epidemic. Geriatric Nursing 24(3): 152-154, 2003. (14 refs.)

Substance abuse is a widely identified problem in our society. Alcohol abuse-is the most problematic, yet most undertreated. Primary care practitioners often do not screen the geriatric population appropriately for at-risk drinking, so the condition goes undiagnosed, This oversight is complicated by the fact that many manifestations of alcohol abuse do not present themselves until well into the disease process. This article explores the practitioner's role in geriatric alcohol abuse assessment and treatment and the impact of geriatric alcohol abuse on society.

Copyright 2003, American Journal of Nursing Co


Kouimtsidis C; Reynolds M; Hunt M; Lind J; Beckett J; Drummond C et al. Substance use in the general hospital. Addictive Behaviors 28(3): 483-499, 2003. (22 refs.)

Introduction: People misusing substances are overrepresented in health settings. Substance misuse can also be an underlying factor complicating medical diagnosis and management. Aims: (i) To establish the prevalence of substance misuse in the general hospital inpatient population; and (ii) to examine the relationship between medical diagnosis and substance misuse problem as identified by screening tools. Method: This study adopted a three-step screening approach including a prospective questionnaire survey, interview, and case note review. Subjects included all adult patients admitted to a London teaching hospital over a 1-week period. Results: Seventy percent completed the questionnaire. Twenty-three percent was currently smoking, 14% was rated positive for alcohol misuse, and 12% positive for drug misuse. Only 65% of patients was screened for smoking, 54% for alcohol, and 9% for other substances. Conclusions: People misusing one substance were more likely to be misusing others, hence the importance of screening all patients for all substances. Doctors were screening a small percentage of patients and they identified and intervened with only the severe ones.

Copyright 2003, Elsevier Science Ltd.


Kozer E; Bar-Hamburger R; Rosenfeld N; Dalal I; Landu O; Fainmesser P et al. Strategy for increasing detection rates of drug and alcohol abuse in paediatric emergency departments. Acta Paediatrica 98(10): 1637-1640, 2009. (30 refs.)

Aim: To determine whether implementation of criteria for performing a toxicology screen and increasing staff awareness improve detection of substance abuse among adolescents presenting to the emergency department. Methods: Patients 12 to 18 years of age presenting to one of three emergency departments in Israel were included in a prospective cohort study. In the 'study' hospital, a set of criteria for urine toxicology screen and measurements of ethanol serum level were implemented. No specific interventions were implemented in the two other hospitals. The main outcome measure was the rate of substance abuse detection. Results: The number of adolescents seen in the participating centres was 3200 at the study hospital, and 3493 and 2792 at the two other hospitals. High blood ethanol concentrations were found in 49 patients at the study hospital compared with 30 and 19 patients at the two other hospitals (p < 0.001). Illicit drugs were detected in 13, 4 and 1 patients, respectively (p = 0.002). Conclusions: Introducing structured guidelines for ordering toxicological screening increases the detection of alcohol and drug of abuse among adolescents presenting to paediatric emergency departments.

Copyright 2009, Wiley-Blackwell


Kozer E; Bar-Hamburger R; Rosenfeld N; Dalal I; Landu O; Fainmesser P et al. Strategy for increasing detection rates of drug and alcohol abuse in paediatric emergency departments. Acta Paediatrica 98(10): 1637-1640, 2009. (30 refs.)

Aim: To determine whether implementation of criteria for performing a toxicology screen and increasing staff awareness improve detection of substance abuse among adolescents presenting to the emergency department. Methods: Patients 12 to 18 years of age presenting to one of three emergency departments in Israel were included in a prospective cohort study. In the 'study' hospital, a set of criteria for urine toxicology screen and measurements of ethanol serum level were implemented. No specific interventions were implemented in the two other hospitals. The main outcome measure was the rate of substance abuse detection. Results: The number of adolescents seen in the participating centres was 3200 at the study hospital, and 3493 and 2792 at the two other hospitals. High blood ethanol concentrations were found in 49 patients at the study hospital compared with 30 and 19 patients at the two other hospitals (p < 0.001). Illicit drugs were detected in 13, 4 and 1 patients, respectively (p = 0.002). Conclusions: Introducing structured guidelines for ordering toxicological screening increases the detection of alcohol and drug of abuse among adolescents presenting to paediatric emergency departments.

Copyright 2009, Wiley-Blackwell


Kramer TL; Robbins JM; Phillips SD; Miller TL; Burns BJ. Detection and outcomes of substance use disorders in adolescents seeking mental health treatment. Journal of the American Academy of Child and Adolescent Psychiatry 42(11): 1318-1326, 2003. (41 refs.)

Objective: To compare detection rates, service use, and outcomes of substance use disorder (SUD) in adolescents seeking mental health treatment. Method: Adolescents (n = 237) and their parents or caregivers completed parallel, self-administered versions of the Adolescent Treatment Outcomes Module (ATOM) at intake and 6-month follow-up. SUD was assessed using the Diagnostic Interview Schedule for Children (DISC). Results: Although 42 (16.6%) adolescents seeking mental health treatment met DISC criteria for any SUD at baseline, clinicians detected only 19 of these (kappa = 0.51). Sensitivity and specificity were high for a screening tool for adolescent SUD (95.2 and 82.0, respectively). Adolescents with undetected SUD were less likely to receive SUD services and to have more legal problems at 6-month follow-up compared to adolescents with detected SUD. Conclusions: SLID rates may be high in adolescents seeking mental health treatment, confirming the need for routine screening in this population. Results confirm that a large gap exists between the need for and access to SUD treatments, which may contribute to poorer outcomes for all adolescents with SUD.

Copyright 2003, American Academy of Child and Adolescent Psychiatry


Lappalainen-Lehto R; Seppa K; Nordback I. Cutting down substance abuse: Present state and visions among surgeons and nurses. (rapid communication). Addictive Behaviors 30(5): 1013-1018, 2005. (19 refs.)

Background. Although substance abuse is variably common among surgical patients, detection of the problem and brief interventions are seldom undertaken. The aim of the present study was to assess surgeons' and nurses' activity in screening substance abuse among their patients and obstacles concerning intervention of patients with substance abuse. Methods: Surgeons and nurses of The Department of Surgery, Tampere University Hospital were asked to predict if the surgical patients treated during a 24-h period (n=211) had a substance abuse disorder. This was compared to the patients' self-reports based on the Alcohol Use Disorders Identification Test (AUDIT) and questions about use of other substances. The surgeons and the nurses were also asked to complete a questionnaire related to interventions of patients with substance abuse; perceived knowledge, skills, attitudes and obstacles. Results: Of the surgical patients, 47 (22%) proved to be substance abusers. Out of them, 23% were detected by surgeons and nurses. Of the surgeons (n=44) 83% and of the nurses (n=332) 84% perceived responsibility for intervention but claimed many obstacles. Nurses reported the lack of knowledge as the main obstacle. Of the nurses 18% reported enough knowledge to conduct the whole brief intervention compared to 34% of surgeons (p=0.021). The main obstacle reported by surgeons was the lack of time. Conclusions: Surgeons and nurses detect only minority of the substance abusing surgical patients. Lack of knowledge and time prevent intervening in patients' substance abuse. These results may be utilized when developing a program to better involve surgeons and nurses in detection and intervention of surgical patients' substance abuse.

Copyright 2005, Elsevier Science


Leslie K. Youth substance use and abuse: Challenges and strategies for identification and intervention. (editorial). Canadian Medical Association Journal 178(2): 145-148, 2008. (20 refs.)


Macias MS; Furton KG. Availability of target odor compounds from seized ecstasy tablets for canine detection. Journal of Forensic Sciences 56(6): 1594-1600, 2011. (14 refs.)

The aim of this study was to compare seized samples of 3,4-methylenedioxy-N-methylamphetamine (MDMA) pills, used to train law enforcement detection canine teams, to determine what differences exist in the chemical makeup and headspace odor and their effect on detectability. MDMA solutions were analyzed by liquid chromatography-mass spectrometry. Analysis of these samples showed a wide variance of MDMA (8-25%). Headspace SPME-GC/MS analysis showed that several compounds such as 3,4-methylenedioxyphenylacetone and 1-(3,4-methylenedioxyphenyl)-2-propanol are common among these MDMA samples regardless of starting compound and synthesis procedure. However, differences, such as the level of the various methylenedioxy starting compounds, were shown to affect the overall outcome of canine detection, indicating the need for more than one MDMA training aid. Combinations of compounds such as the primary odor piperonal in conjunction with a secondary compound such as MDP-2-OH or isosafrole are recommended to maximize detection of different illicit MDMA samples.

Copyright 2011, Wiley-Blackwell


Magnusson A; Goransson M; Heilig M. Unexpectedly high prevalence of alcohol use among pregnant Swedish women: Failed detection by antenatal care and simple tools that improve detection. Journal of Studies on Alcohol 66(2): 157-164, 2005. (46 refs.)

Objective: We examined the use of alcohol during early pregnancy in urban Swedish women, the ability of Swedish antenatal care to identify alcohol-related risk pregnancies and the utility of some potential tools for improving its performance. Method: Women attending regular antenatal care were randomized to regular assessment only (control, n = 156) or intensified screening (intervention, n = 147). In the intervention group, alcohol use was determined using the Timeline Followback (TLFB) interview, alcohol use habits with the Alcohol Use Disorder Inventory Test (AUDIT), and biomarkers for alcohol use were analyzed. Data were typically obtained in pregnancy week 12. Results: In the intervention group as a whole, average absolute alcohol consumption during the first 6 weeks of pregnancy was low but highly variable (mean [SD] = 24.9 [50.5] g/week; 4.8 [6.0] episodes for the entire 6 week period); 22 women (15%) drank at levels exceeding 70 g/week during any 2 or more weeks and/or in a heavy episodic drinking pattern, 60 g/episode, on 2 or more episodes. The AUDIT had a moderate sensitivity (54%) to identify these subjects. Biomarkers identified subjects with somatic illness rather than high alcohol consumption. In the control group, only 4 (3%) were identified as using alcohol, indicating a probable underestimation of alcohol use by regular antenatal screening procedures (p = .0001). Conclusions: An unexpected proportion of pregnant women in urban Sweden consume alcohol at levels likely to produce adverse effects. Regular antenatal care did not identify most of these risk pregnancies. The TLFB identified pregnant women with risk use of alcohol during pregnancy who were only partly identified by analyzing prepregnancy alcohol use patterns with the AUDIT. Elevated laboratory markers likely indicated somatic illness rather than harmful drinking.

Copyright 2005, Alcohol Research Documentation, Inc. Used with permission


Malet L; Llorca PM; Boussiron D; Schwan R; Facy F; Reynaud M. General practitioners and alcohol use disorders: Quantity without quality. Alcoholism: Clinical and Experimental Research 27(1): 61-66, 2003. (45 refs.)

Background: General medical practitioners are essential for the prevention, diagnosis, and management of alcohol use disorders. Studies to examine medical practice in this field, however, are very rare. Method: A cross-sectional study involving 2010 patients seen by a sample of 145 general practitioners in the Auvergne region of central France was conducted on a given day in May 1998. The purpose of the study was to evaluate the prevalence of alcohol use disorders (using the DSM-IV diagnostic criteria for alcohol abuse or dependence and the CAGE questionnaire) and so to estimate the proportion of nonsomatic alcohol-related care dispensed. Results: Sixteen percent of patients consulting their general practitioner had an alcohol problem, 27% of men and 5% of women. On average, a quarter of these patients had not been previously identified by the physician. Diagnosis seemed particularly difficult in women: 11% of women aged between 36 and 45 had an alcohol- related problem that went unidentified in 60% of cases. Care for alcohol-related health problems was therefore seriously inadequate. In one third of cases, patients with a diagnosed alcohol-related problem were not followed up by the physician for that problem. Two thirds received no medication, and in more than 80% of cases the physician did not refer to a specialist or prescribe admission to a specialized hospital ward. Conclusions: These results underline the diagnostic and therapeutic difficulties experienced by general practitioners. This study has led to the establishment of a pilot health care network for patients suffering from alcohol use disorders. This network involves voluntary doctors who have been trained and are better paid for their services. Care protocols have been established to which these practitioners have to adhere.

Copyright 2003, Research Society on Alcoholism. Used with permission


Marshall KL; Deane FP. General practitioners' detection and management of patients with a dual diagnosis: Implications for education and training. Drug and Alcohol Review 23(4): 455-462, 2004. (38 refs.)

General practitioners (GPs) are in a unique position to detect and manage patients with co-morbid mental health and substance use disorders (dual diagnosis). It has been estimated that over 30% of patients presenting to general practice have a diagnosable mental disorder and 12% have dual diagnosis. Unfortunately, between 30 and 50% of these problems go undetected in general practice. Limited GP education and training in mental health may account for this deficit, with a little over 8% of GPs receiving any formal postgraduate training in mental health. Prior to developing an educational resource for GPs, the present study aimed to establish baseline estimates of GP treatment practices with patients who have dual diagnosis. Two GP division-wide surveys of screening, assessment and treatment for dual diagnosis were conducted one year apart. In addition, five GPs conducted a clinical audit of 508 patient consultations. Results indicate that without ongoing targeted interventions, patient management activities such as GP counselling, use of screening devices, referral to specialist services, coordination and use of EPC items are not likely to improve and are at risk of declining.

Copyright 2004, Carfax Publishing


Martyr P; Janca A. A mad mayor of Fremantle: the mysterious illness of Edward Davies. Australasian Psychiatry 19(6): 479-483, 2011. (30 refs.)

Objective: The aim of this paper is to illustrate how a person's standing in a small, close-knit community can distort local medical and legal attitudes to their diagnosis. We examined various historical texts describing Edward Davies (1855-1904), Mayor of Fremantle, and the medical, legal and family responses to his illness. Conclusions: When Davies developed an apparently serious mental illness, his family was able to keep this behaviour hidden for some time. However, when evidence of his illness finally erupted into the public eye, it led to a ground-breaking 1903 case in the WA Supreme Court in Lunacy. It is clear that Davies ' defenders wanted him to be diagnosed and treated as an alcoholic, when in fact he may have had late onset psychosis, complicated by alcohol abuse. With the increasing amount of historical material available through Australian digitized newspaper collections, new scope is opening up for retrospective diagnosis.

Copyright 2011, Informa Healthcare


McMillan GP; Timken DS; Lapidus J; C'de Baca J; Lapham SC; McNeal M. Underdiagnosis of comorbid mental illness in repeat DUI offenders mandated to treatment. Journal of Substance Abuse Treatment 34(3): 320-325, 2008. (25 refs.)

Repeat offenders for DUI are routinely mandated to undergo alcohol treatment. These individuals have been shown to have high rates of co-occurring psychiatric disorders, which can be important for the conduct and outcomes of alcohol treatment. The extent to which treatment providers are aware of these disorders and modify treatment accordingly is unknown. As part of a larger study to investigate the impact of sanction conditions on probation outcomes, we screened 233 patients for psychiatric conditions and compared the findings with the psychiatric conditions identified during mandatory treatment by independent treatment providers. Adjusted rates of underdiagnosis were commonly high: 97.2% of bipolar disorder cases, 67.5% of major depression cases, 100% of obsessive-compulsive disorder cases, and 37.3% of drug use disorder cases remained undiagnosed during treatment. Rates of overdiagnosis were low for all disorders, with the exception of drug use disorders. These rates of underdiagnosis represent missed opportunities to improve treatment outcomes among repeat DUI offenders.

Copyright 2008, Elsevier Science


Midanik LT; Armstrong MA; Lieberman L; Osejo VG. Using chart reviews to assess postpartum substance use: A pilot study. Social Work in Health Care 38(4): 25-35, 2004. (16 refs.)

The use of chart reviews to assess substance use one-year postpartum was examined in this pilot study by comparing interviews with chart reviews for 23 women assessed positive for risk during pregnancy. There was no indication that providers asked about alcohol use in 83 percent of the charts, drug use in 57 percent of the charts, and tobacco use in 26 percent of the charts. Few positive or negative matches between interviews and chart reviews were found because substance use was generally not noted. These findings underscore the need to interview women to obtain postpartum substance use information and suggest that providers may not adequately address this issue.

Copyright 2004, Haworth Press, Inc.


Monras M; Aparicio A; Lopez JA; Pons I. Prevalence of alcohol consumption related disorders in a prison population convicted of crimes against road safety. Actas Espanolas de Psiquiatria 39(3): 163-167, 2011. (18 refs.)

Introduction. Alcohol consumption is a major cause of traffic accidents, so that stricter laws have been enacted to avoid it. Despite this, there are still persons who break the law and go to prison because of driving under the effects of alcohol. We have investigated if these persons are occasionally alcohol drinkers or if they are alcoholics with difficult to modify alcohol patterns. Material and methods. A cross-sectional study including 50 inmates from two prisons who had committed traffic crimes were interviewed about their alcohol consumption habits and their criminal and psychopathological backgrounds. Results. 88% had indicators of alcoholism and most consumed other drugs. Previous psychopathology signs were only detected in 10% of the sample. A total of 72% had previous criminal records, half because of violent offences. They were socially adapted, with mean age 39 years, Spanish (86%), had a stable job and family (76%). Conclusions. Most of the inmates due to traffic crimes are alcoholic, but very few are detected. Their alcohol consumption generates other criminal conduct, treatment being necessary in order to avoid relapse and social exclusion.

Copyright 2011, Juan Jose Lopez-Ibor Foundation


Mordal J; Holm B; Morland J; Bramness JG. Recent substance intake among patients admitted to acute psychiatric wards: Physician's assessment and on-site urine testing compared with comprehensive laboratory analyses. Journal of Clinical Psychopharmacology 30(4): 455-459, 2010. (21 refs.)

This cross-sectional study of acute psychiatric admissions compared physicians' assessments of recent substance intake and on-site urine testing with comprehensive laboratory drug analyses. The sample comprised 325 consecutive admissions from 2 acute psychiatric wards. Physicians on call were asked to judge if the patient had recently taken benzodiazepines, opiates, alcohol, amphetamines, cannabis, or cocaine. Blood and urine samples were obtained and analyzed with chromatographic laboratory methods for a wide range of substances. A routine on-site urine screening test was performed in 92 of the cases. Physicians' assessments and on-site urine testing were compared with the reference standard of laboratory analyses. The sensitivity of the physician's assessment was highest for amphetamines (76%), followed by benzodiazepines (61%), opiates (57%), cannabis (55%), and cocaine (50%), whereas specificity was greater than 90% for all substances. The sensitivity of the on-site test ranged from 76% for amphetamine to 97% for cannabis, and specificity ranged from 82% for cannabis to 100% for cocaine. The study indicates clinical underdetection of recent substance intake among acute psychiatric admissions. On-site urine testing identified substance use that was not recognized by the physician's initial assessment, although specificity for cannabis and benzodiazepines was low. Chromatographic methods, which offered important supplementary information about substance use, should be considered for the routine screening of acutely admitted psychiatric patients.

Copyright 2010, Lippincott, Williams & Wilkins


Mordal J; Holm B; Morland J; Bramness JG. Recent substance intake among patients admitted to acute psychiatric wards: Physician's assessment and on-site urine testing compared with comprehensive laboratory analyses. Journal of Clinical Psychopharmacology 30(4): 455-459, 2010. (21 refs.)

This cross-sectional study of acute psychiatric admissions compared physicians' assessments of recent substance intake and on-site urine testing with comprehensive laboratory drug analyses. The sample comprised 325 consecutive admissions from 2 acute psychiatric wards. Physicians on call were asked to judge if the patient had recently taken benzodiazepines, opiates, alcohol, amphetamines, cannabis, or cocaine. Blood and urine samples were obtained and analyzed with chromatographic laboratory methods for a wide range of substances. A routine on-site urine screening test was performed in 92 of the cases. Physicians' assessments and on-site urine testing were compared with the reference standard of laboratory analyses. The sensitivity of the physician's assessment was highest for amphetamines (76%), followed by benzodiazepines (61%), opiates (57%), cannabis (55%), and cocaine (50%), whereas specificity was greater than 90% for all substances. The sensitivity of the on-site test ranged from 76% for amphetamine to 97% for cannabis, and specificity ranged from 82% for cannabis to 100% for cocaine. The study indicates clinical underdetection of recent substance intake among acute psychiatric admissions. On-site urine testing identified substance use that was not recognized by the physician's initial assessment, although specificity for cannabis and benzodiazepines was low. Chromatographic methods, which offered important supplementary information about substance use, should be considered for the routine screening of acutely admitted psychiatric patients.

Copyright 2010, Lippincott, Williams & Wilkins


National Quality Forum. National Quality Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Washington DC: National Quality Forum, 2007. (24 refs.)

This report grew out of a consensus conference convened by the National Quality Forum. The Executive Summary notes that over the past 15 years, scientific knowledge has substantially increased in respect to treating substance use conditions and that there is growing recognition of substance abuse/dependence as a chronic medical condition. This report assembles a set of 11 detailed, fully specified, evidence-based practices. For each practice the target outcomes are identified, the procedures involved specified, as well as for whom it is intended, the settings in which it is provided, and the personnel involved in providing the services. The practices outlined are applicable across a range of populations, diverse settings, and providers. They fall into four domains - identification of substance use conditions, initiation and engagement in treatment, therapeutic interventions, and continuing care management . These practices include: (1) screening and case finding; (2) adoption of systematic methods and procedures to accomplish case finding; (3) diagnosis and assessment for those with positive screening; (4) brief interventions by a trained clinician; (5) provision of support and other services to promotion initiation of care; (6) management of withdrawal, a necessary precursor of treatment of the substance abuse condition; (7) psychosocial interventions; (8-10) pharmacotherapy for opiate, alcohol and nicotine dependence as an adjunct to psychosocial service; and (11) continuing care management and monitoring. For each of these elements the practice domain is identified, as well as the target outcome, and specification of what is involved. A series of appendices set forth the Members and Board of Directors (drawn from major medical centers, representatives of all major medical professional societies as well as private foundations, and governmental agencies), the members of the Steering Committee and Technical Advisory Panel, selected references, and a summary of the consensus development process.

Copyright 2008, Project Cork


Olfson M; Tobin JN; Cassells A; Weissman M. Improving the detection of drug abuse, alcohol abuse, and depression in community health centers. Journal of Health Care for the Poor and Underserved 14(3): 386-402, 2003. (47 refs.)

Up to 35 percent of primary care patients suffer from substance abuse or mental disorders, and most of these patients receive care from general medical professionals rather than mental health specialists. Accumulating evidence suggests that primary care physicians often fail to recognize, diagnose, and treat their patients with mental and substance use disorders; only about 5 percent of primary care visits result in a mental or substance use diagnosis. The goals of this project were to evaluate the feasibility of screening for drug abuse, alcohol abuse, and major depression at two federally funded urban Community/Migrant Health Centers (C/MHCs), in Newark, New Jersey, and Bronx, New York, and to examine the effects of a clinical tool designed to guide primary care clinicians in the identification and treatment of substance use and depression, assess provider perceptions of the screening form, and determine the concordance between provider and patient reports Of assessment and management.

Copyright 2003, Institute on Health Care for the Poor and Underserved, Meharry Medical College


Owens L; Gilmore IT; Pirmohamed M. How do NHS general hospitals in England deal with patients with alcohol-related problems? A questionnaire survey. Alcohol and Alcoholism 40(5): 409-412, 2005. (23 refs.)

Aims: Alcohol-related disease represents a major burden on hospitals. However, it is unclear whether hospitals have developed the necessary expertise and guidelines to deal with this burden. The aim of this survey was to determine what measures general hospital NHS Trusts in England had in place to deal with alcohol-related problems, including the employment of dedicated alcohol specialist nurses. Methods: Two postal surveys of all NHS general hospital Trusts in England, the first in 2000 (n = 138; 54% response rate) and the second in 2003 after the publication of the Royal College of Physicians (RCP) report on alcohol in secondary care (n = 164; 75% response rate). Results: Between the two surveys, there was a significant increase (P = 0.005) in the number of dedicated alcohol nurses employed by general hospital trusts; however, the numbers remain low (n = 21). Additionally, the availability of prescribing guidelines for the management of alcohol withdrawal increased significantly (P = 0.0001). Conclusions: The survey indicates that most general hospitals do not have appropriate services in place to deal with such patients. Although there is a need and willingness to develop alcohol services in general hospitals, which is one of the key recommendations of the RCP report, the lack of funding is going to act as a major barrier.

Copyright 22005, Oxford University Press


Paganelli A; LoBello SG; Mehta S; Ray GE. The influence of patient age and alcohol relevant laboratory values on physicians' diagnoses of alcoholism. Journal of Applied Biobehavioral Research 9(2): 106-121, 2004. (43 refs.)

This study investigated factors that contribute to physicians' diagnoses and ratings of prognosis when reviewing vignettes of hypothetical cases constructed to reflect alcohol dependence. Forty-nine medical residents who read the vignettes were asked to list three probable diagnoses and a prognosis. Patient descriptions in the hypothetical vignettes were identical except for age (35 years vs. 70 years) and inclusion of alcohol-relevant lab values (present vs. absent). Results indicated that the younger patient described in the vignettes was diagnosed with alcoholism more often than was the older patient. The presence of alcohol-relevant lab values was unrelated to a diagnosis of alcoholism. Prognosis, which was on average rated as fair for most patients, was unrelated to the age of the patient.

Copyright 2004, Bellwether Publishing Ltd.


Peterson AL; Hryshko-Mullen AS; Cortez Y. Assessment and diagnosis of nicotine dependence in mental health settings. American Journal on Addictions 12(3): 192-197, 2003. (28 refs.)

This study evaluated the frequency of documented assessment of smoking status and the diagnosis of nicotine dependence in a random sample of 153 mental health records and 152 medical records. The results indicated that tobacco use was routinely documented in the mental health records (88%) and medical records (87%). However, a diagnosis of nicotine dependence was given in only 2% of the mental health records (1/49) and 7% of the medical records (2/30) for those patients with documented regular tobacco use. These results suggest that clinicians do not routinely diagnose Nicotine Dependence even when diagnostic criteria are met.

Copyright 2003, American Academy of Psychiatrists in Alcoholism and Addictions


Rapley T; May C; Kaner EF. Still a difficult business? Negotiating alcohol-related problems in general practice consultations. Social Science & Medicine 63(9): 2418-2428, 2006. (29 refs.)

This paper describes general practitioners' (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews-two with GPs and one with a primary care team-where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, reintroduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with [Thom, B., & Tellez, C. (1986). A difficult business-Detecting and managing alcohol-problems in general-practice. British Journal of Addiction 81, 405-418] seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expanded.

Copyright 2006, Elsevier Science


Rockett IRH; Putnam SL; Jia HM; Smith GS. Assessing substance abuse treatment need: A statewide hospital emergency department study. Annals of Emergency Medicine 41(6): 802-813, 2003. (63 refs.)

Study objective: Health Care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagnoses for adult ED patients in medical records with treatment need assessed through self-report, toxicologic screening, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria. Methods: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Main outcome measures were the prevalence of diagnosed substance abuse problems, positive bioassay results, denied use, and treatment need. Sensitivity and multivariate analyses, were conducted by using varied case definitions of treatment need. Results: Thirty-one percent (95% confidence interval [CI] 27.3% to 34.7%) of screened ED patients (n=1,330) had positive test results for substance use. Their prevalence of denial of use in the 30 days before the survey ranged from 10% for alcohol (95% CI 5.7% to 14.3%) to 100% for phencyclidine. One percent of all ED patients (n=1,502) had a recorded diagnosis of substance abuse. By contrast, as many as 27% (95% CI 23.3% to 31.8%) were assessed as needing substance abuse treatment on the basis of a comprehensive case definition that accounted, for denial; and positive test results. A sensitivity analysis using other case definitions is also presented. For example, 4% (95% CI 2.8% to 5.3%) of patients met the very strict definition of DSM-IV current drug dependence only. Under the comprehensive case definition, TennCare patients (adjusted odds ratio [OR] 1.63; 95% CI 1.30 to 2.05) and Medicare patients (adjusted OR 2.50; 95% CI 1.34 to 4.65) showed excess treatment need relative to the privately insured. Excess need was also exhibited by patients reporting I or more prior ED visits in the past year (adjusted OR 1.62; 95% CI 1.13 to 2.31) and by patients taking 2 or more hours to reach the ED after the onset of injury or illness (adjusted OR 1.54; 95% CI 1.16 to 2.04). Treatment need was inversely associated with age. Irrespective of case definition, less than 10% of ED patients who needed substance abuse treatment were receiving such treatment. Conclusion: EDs can be important venues for detecting persons in need of substance abuse treatment.

Copyright 2003, American College of Emergency Physicians. Used with permission


Saitz R; Horton NJ; Sullivan LM; Moskowitz MA; Samet JH. Addressing alcohol problems in primary care: A cluster randomized, controlled trial of a systems intervention: The screening and intervention in primary care (SIP) study. Annals of Internal Medicine 138(5): 372-382, 2003. (138 refs.)

Background: screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented. Objective: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use. Design: Cluster randomized, controlled trial. Setting: Urban academic primary care practice. Participants: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking. Interventions: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit. Measurements: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later. Results: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.71 versus 11.6 [CI, 5.4 to 17.7]). Conclusions: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

Copyright 2003, American College of Physicians


Shourie S; Conigrave KM; Proude EM; Haber PS. Detection of and intervention for excessive alcohol and tobacco use among adult hospital in-patients. Drug and Alcohol Review 26(2): 127-133, 2007. (33 refs.)

Early detection and intervention for alcohol problems have been shown to reduce subsequent health consequences. However, the extent to which these practices have been implemented is unclear. The study assessed among hospital in-patients (1) the prevalence of at-risk drinking and smoking, (2) current practice in detection and intervention for at-risk drinking and smoking and (3) self-reported effect of any intervention. A brief self-administered questionnaire was administered to adult in-patients addressing alcohol use [ Alcohol Use Disorders Identification Test (AUDIT) questionnaire], smoking and self-reported effect of any recent intervention for drinking or smoking. The participant's smoking status and alcohol use as recorded by medical and nursing staff was compared to self-reports. Of 448 in-patients, 50% ( 226) participated in the study; 38% (170) were ineligible and 12% (52) refused. Participants were aged 61.3 (+/-18.9) years. A higher number of problem drinkers (11.9% vs. 3.5%, p < 0.0001) and current smokers (17.3% vs. 9.3%, p < 0.0001) were identified by the questionnaire compared to the medical records. Hospital staff quantified smoking more consistently than alcohol (54% vs. 42%, p = 0.02). Of those who recalled an intervention, 19% of drinkers and 27% of smokers said they had stopped drinking or smoking for a period since that intervention. Further improvement is required in the rates of detection and interventions for alcohol use disorders and smoking in the hospital setting.

Copyright 2007, Taylor and Francis


Sims C; Sabra D; Bergey MR; Grill E; Sarani B; Pascual J et al. Detecting intimate partner violence: More than trauma team education is needed. Journal of the American College of Surgeons 212(5): 867-872, 2011. (31 refs.)

BACKGROUND: Intimate partner violence (IPV) is an underappreciated cause of morbidity and mortality in female trauma patients. We investigated the impact of a domestic violence education program for trauma residents on the detection of IPV. STUDY DESIGN: In January 2008, an educational IPV program was implemented for all trauma residents. A retrospective review of all female patients evaluated by the trauma service before and after institution of the IPV program was performed. Medical records were reviewed for demographic data, injury mechanism, social habits, and IPV documentation. Chi-square and Fisher's exact tests were used to compare patients before and after institution of the educational IPV program. RESULTS: The records of 645 female trauma patients evaluated in 2007 and 2008 were reviewed. Patients were not routinely asked about IPV, despite implementation of the educational program; 39.9% were asked about IPV in 2007 versus 46.1% in 2008 (p = 0.11). The positive disclosure of IPV did not increase from 2007 to 2008 (20.1% versus 21.2%; p = 0.83). Documentation about social habits increased considerably. In 2008, patients were asked more regularly about alcohol (71.8% versus 80.8%; p = 0.01), drugs (64.1% versus 73.7%; p = 0.01), and tobacco use (67.0% versus 78.1%; p = 0.002). Importantly, patients with documented IPV (n = 57) frequently presented to the trauma team with nonviolent mechanisms of injury (n = 30, 52.6%). CONCLUSIONS: IPV is a frequent finding in female trauma patients. Despite increased education, questions about IPV are not documented routinely. In addition, screening at-risk patients by mechanism will underestimate the prevalence of IPV. Universal screening should be mandated to increase IPV detection and enhance opportunities for intervention.

Copyright 2011, Elsevier Science


Sise MJ; Sise CB; Kelley DM; Simmons CW; Kelso DJ. Implementing screening, brief intervention, and referral for alcohol and drug use: The trauma service perspective. Journal of Trauma 59(3, Supplement): s112-s118, 2005. (24 refs.)

Background. Most trauma surgeons are unfamiliar with screening, brief intervention, and referral (SBIR) programs for substance use disorders, and few trauma centers provide them. This report describes how an urban private-teaching hospital adapted a protocol from an existing emergency department-based program to include patients treated by the trauma service. Methods. We recorded the rates of SBIR completion and reasons for failure during each phase of the implementation, interviewed trauma service staff and health educators to assess attitudes toward the program, and evaluated patient satisfaction surveys. Results: By adding SBIR staff to the trauma outpatient clinic and to trauma morning rounds, the capture rate increased from 12 to 71%. Most screened patients (59%) were found at risk for problems or probably dependent on alcohol or drugs. Trauma service staff and health educators reported high satisfaction with the program. Patients reported higher satisfaction with SBIR. Conclusion: SBIR services can be effectively integrated into all components of a busy, urban trauma service by adding specially trained health educators to the trauma service staff. This collaboration provides effective SBIR services to both trauma and emergency service patients without interfering with patient care or medical procedures. The relatively high percentage of patients at risk for alcohol or drug problems supports the inclusion of routine alcohol and drug screening for all eligible trauma patients.

Copyright 2005, Lippincott, Williams & Wilkins


Smothers BA; Yahr HT; Ruhl CE. Detection of alcohol use disorders in general hospital admissions in the United States. Archives of Internal Medicine 164(7): 749-756, 2004. (40 refs.)

Background: Previous studies in which research-based assessment for alcohol problems at admission was compared with physician diagnoses indicated that many alcohol diagnoses in hospitalized patients were missed. We estimated the extent to which hospital records documented detection of alcohol abuse or dependence and other alcohol-related problems in a national sample of hospital admissions having a research-based diagnosis of alcohol use disorder ("interview-positive admissions"). We also estimated rates of inpatient alcohol intervention and referral for treatment. Methods: A complex, multistage, probability sample was designed to represent nonmaternity, acute-care admissions to nonfederal, short-stay, general hospitals in the contiguous United States. The study included 2040 admissions, 1613 male and 427 female. Research-based diagnoses of current (ie, past 12 months) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol use disorder were derived from a structured, computer-assisted, personal interview containing the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Information on detection, inpatient intervention, and treatment referral were obtained via retrospective analysis of closed hospital records covering the index visit. Results: Record-documented diagnoses of alcohol-related problems were found in 40% to 42% of interview-positive admissions. Inpatient intervention rate was estimated at 21% for interview-positive admissions, and treatment referral rate, 24%. For detected interview-positive admissions, estimated rates of intervention and referral were 50% and 53%, respectively. Conclusions: Estimated rates of detection, inpatient intervention, and treatment referral of alcohol use disorders in hospital admissions were low. Current-drinking hospital admissions should be screened for alcohol problems as part of the admission routine, with further professional evaluation, intervention, and treatment referral as indicated.

Copyright 2004, American Medical Association


Stewart SH; Miller PM. Detecting alcohol use disorders in recently hospitalized persons: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Addiction Medicine 1(1): 40-43, 2007. (16 refs.)

Pharmacotherapy combined with medical management, an increasingly viable option for treating alcohol use disorders in health care settings, requires rapid and reliable diagnosis. This study explored a simple screening approach in persons with recent general hospital admission who participated in the National Epidemiologic Survey on Alcohol and Related Conditions reporting hospitalization during the past year (n = 4537). The survey included detailed assessment of alcohol consumption and full diagnostic assessment for alcohol use disorders. The sensitivity and specificity of 1 heavy drinking day question were estimated by using methods appropriate for complex survey data. Results showed that, among recently hospitalized persons consuming any alcohol in the past year, a response of at least 1 heavy drinking day during that time was 86% sensitive and 77% specific for current alcohol use disorders. The item performed better for alcohol dependence than abuse. False-negative screens were associated with older age and less alcohol consumption. Because of its brevity and compatibility with a typical admission history, the heavy drinking day item should be considered for screening current drinkers at the time of hospitalization. However, future research also should validate this screen at the point of care.

Copyright 2007, American Society of Addiction Medicine


Ta VM; Holck P; Chen T; Zane N. Patients' reports about medical doctors' inquiries on their mental health: Do generational status, ethnicity and mental health/substance use disorders matter? Journal of Health Care for the Poor and Underserved 22(4): 1369-1386, 2011. (50 refs.)

Immigrants are less likely than others to use mental health (MH) services. Physicians' limited time often precludes inquiry about MH. This study investigated the influence of generational status, ethnicity, and mental/substance use disorders on physicians' inquiries about Asian American (AA) MH. Data from the National Latino and Asian American Study were analyzed (n=1,853). The outcome was past year physician's inquiry regarding MH. Results revealed that AA with U.S.-born parents had significantly greater odds compared to AA born outside the U.S. to report that their doctors inquired about their M H (OR=2.18, 95% CI: 1.28, 3.73). Past year mental/substance use disorder increased the odds of AA reporting that their doctors inquired about their MH (OR=8.41; 95% CI: 3.28, 21.66). This increase differed by ethnicity, with Chinese less affected than Vietnamese (OR=0.17; 95% CI: 0.05, 0.59). The reasons for these associations warrant further exploration.

Copyright 2011, Johns Hopkins University Press


Torres LR; Zayas LH; Cabassa LJ; Perez MC. Diagnosing co-occurring substance-related disorders: Agreement between SCID, Hispanic clinicians, and non-Hispanic clinicians. Journal of Clinical Psychiatry 68(11): 1655-1662, 2007. (32 refs.)

Objective: Given the composition of the mental health and substance abuse workforce in the United States, Hispanic immigrants are often assigned to non-Hispanic, English-speaking clinicians. This produces challenges in communication and in understanding linguistic and cultural nuances and greatly impacts the accuracy of diagnoses and the delivery of appropriate services. With the inclusion of objective criteria in diagnostic categories, clinician-to-clinician agreement ought not to be impacted by the ethnicity of the client or the clinician. Both practice and research, however, suggest that this is not the case, particularly when diagnosing co-occurring mental health and substance abuse disorders. We explored the degree to which Hispanic and non-Hispanic clinicians agreed with each other and with the Structured Clinical Interview for DSM-IV-TR, Research Version (SCID) when diagnosing co-occurring substance-related disorders. Method: Using a naturalistic design, 88 adult clients were videotaped in diagnostic intake interviews (utilizing the DSM-IV-TR) with Hispanic or non-Hispanic clinicians. Videotapes were then viewed and rated by clinicians who were ethnically cross-matched to those on tape. Clients were also administered the SCID. Data were collected from September 15, 2003, through February 7, 2005. Results: Non-Hispanic clinicians diagnosed significantly more substance-related disorders than Hispanic clinicians, and both Hispanic and non-Hispanic clinicians significantly under-diagnosed substance-related diagnoses compared to the SCID. Clinicians had very low diagnostic reliability with each other and with the SCID. Implications for the assessment, diagnosis, and treatment of co-occurring substance-related disorders are discussed. Conclusion: Findings seem to concur with past research suggesting that clinicians may be influenced by factors other than the diagnostic criteria (e.g., cultural and social biases) when diagnosing, and that they may make erroneous attributions of pathology when diagnosing across cultures.

Copyright 2007, Physicians Postgraduate Press


Trautman DE; McCarthy ML; Miller N; Campbell JC; Kelen GD. Intimate partner violence and emergency department screening: Computerized screening versus usual care. Annals of Emergency Medicine 49(4): 526-534, 2007. (45 refs.)

Study objective: To compare a computer-based method of screening for intimate partner violence (intimate partner violence) with usual care in an emergency department (ED) setting. Methods: During 3 distinct but consecutive 2-week periods, women who presented to the ED were asked to complete a computer-based health survey with or without intimate partner violence screening questions in addition to receiving usual intimate partner violence care (ie, screened voluntarily by ED providers and documented in medical record). The screening, detection, referral and service rates were compared between women who completed the computer-based health survey with the intimate partner violence screening questions to usual care. Results: Of the 411 women who completed the computer-based health survey with the intimate partner violence questions, 99.8% were screened for intimate partner violence compared to 33% of the 594 women who received usual care (67.1% difference; 95% CI 63.3%, 70.9%). The computer-based health survey detected 19% intimate partner violence positive whereas usual care detected 1% (17.8% difference; 95% Cl 13.9%, 21.7%). Referral to social work was higher among those screened by the computer-based health survey (10%) versus usual care (< 1%) (9.7% difference; 95% CI 6.7%, 12.7%). Only 20 subjects received intimate partner violence services, although it was slightly higher among those screened by the computer-based health survey (4%) compared to usual care (1%) (4.0% difference; 95% Cl 2.0%, 6.1%). Conclusion: We found that a computer-based approach led to significantly higher intimate partner violence screening and detection rates compared to usual care. Receipt of intimate partner violence services was also higher than usual care but was not optimal. Computer technology makes routine screening easier and allows us to redirect our energies to addressing patients' intimate partner violence problems.

Copyright 2007, Elsevier Science


Verrill C; Smith S; Sheron N. Are the opportunities to prevent alcohol related liver deaths in the UK in primary or secondary care? A retrospective clinical review and prospective interview study. Substance Abuse Treatment, Prevention, and Policy 1(e-article 16), 2006. (17 refs.)

Background: Deaths from liver cirrhosis have increased at least 8 fold since the 1970's in the UK and further increases are anticipated, whereas in the rest of Europe liver deaths are decreasing. In the UK, we urgently need strategies to detect those who misuse alcohol and are at risk of developing alcoholic liver disease before they get to that point. One potential strategy is to screen admissions to hospital with alcohol related conditions for evidence of alcohol misuse. Surprisingly, there has been no research into the important question of where the opportunities are to detect those who misuse alcohol - primary or secondary care. We attempted to answer this firstly by conducting a retrospective analysis of the medical notes of 94 patients diagnosed with alcohol induced liver cirrhosis between 1st January 1995 and 31st December 2000 at Southampton General Hospital with the purpose of identifying admissions to hospital prior to a diagnosis of alcoholic liver disease. In the second part of the study, we interviewed patients with alcoholic liver disease about their contact with health services. Results: Before diagnosis of alcoholic liver disease, 33% (31/94) of the patients had had an admission to hospital for an alcohol related condition. There was a mean of 7 years and 1 month (SD 6 years 3 months) between the first alcohol-related admission and presentation with alcoholic liver disease (in those who had had admissions). The commonest reason for alcohol related admission was falls/fractures/injuries, followed by non-variceal gastro-intestinal bleeds. Patients with alcoholic liver disease who were interviewed had seen their General Practitioner on average at least 2 times per year. Conclusion: Most patients who develop alcohol-induced cirrhosis do not have an admission to hospital with an alcohol related condition before developing alcoholic liver disease. Therefore, if we screen patients admitted to hospital with alcohol related conditions for evidence of alcohol misuse, we could potentially detect around a third of those at risk of developing cirrhosis. Although secondary care has an important role to play in detecting those at risk, the main opportunity for detection is in primary care.

Copyright 2006, BioMed Central


Vorkapic ST; Dadic-Hero E; Ruzic K; Roncevic D; Knez R. Proposal for a new detection method of substance abuse risk in Croatian adolescents. Annali Dell Istituto Superiore Di Sanita 47(3): 316-319, 2011. (21 refs.)

One of the most important factors of successful substance abuse treatment is the early start of the same treatment. Recent selection method for identification of Croatian adolescents in the substance abuse risk that has been using drug tests from urine samples, has been simple and exact on the one hand, but on the other, has been very rare and usually guided by the pressure of parents or the court. Besides, such method presented the source of legal and ethical questions. So, the proposal of application of standardized psychological tests during systematic medical exams of Croatian adolescents at the age range of 15-22 years could help with the early detection of those adolescents who were in the substance abuse risk or already had the developed addiction problem.

Copyright 2011, Editrice Kurtis


Walther M; Montse B; Silvia M; Gemma N; Antoni G. Teaching hospital staff about hazardous drinking: The effect of a single intervention. Alcohol and Alcoholism 43(1): 51-52, 2008. (9 refs.)

Aims: To determine if a teaching intervention on hazardous drinking could improve the knowledge, attitudes and clinical behaviour of Health Professionals (HP) in a hospital. Methods: Changes were assessed at baseline and 1 month after the intervention through questionnaires delivered to 38 professionals and interviews with patients (N=240). Results: Knowledge of professionals improved. No changes were observed through patients interviews. Conclusions: A single teaching session produces modest but significant changes in the management of alcohol related issues in hospital staff.

Copyright 2008, Oxford University Press


Weisner C; Matzger H. Missed opportunities in addressing drinking behavior in medical and mental health services. Alcoholism: Clinical and Experimental Research 27(7): 1132-1141, 2003. (69 refs.)

Background: Epidemiological and clinical literature point to the importance of screening for alcohol problems in medical and psychiatric settings. However, little is known about which problem drinkers seek help from those services or about the characteristics of those who have their drinking addressed. Methods: We interviewed a probability sample of adult dependent and problem drinkers in the general population (n = 672) and consecutive admissions to chemical dependency programs in a northern California county (n = 926). We reinterviewed them 1 year later and measured medical and mental health visits and whether their drinking was addressed during the visit. Results: Almost two-thirds of problem drinkers had a medical visit, and approximately one-third had a mental health visit, yet drinking was not often discussed, especially during medical visits. Many of those more likely to have a visit were not more likely to have their drinking addressed. Women and individuals older than 40 years had more medical and mental health visits [odds ratio (OR), 1.71; p < 0.001 and OR, 1.55; p < 0.001, respectively, for women; OR, 157; p < 0.05 and OR, 1.64; p < 0.05, respectively, for age greater than or equal to40 years], but were not more likely to have their drinking addressed in either setting, and women were less likely than men to have their drinking addressed in mental health settings (OR, 0.62; p < 0.05). Those with higher alcohol severity and those who had attended chemical dependency treatment during the previous year were more likely to have their drinking addressed in each setting. Insurance status predicted medical, but not mental health, visits and was not related to having drinking addressed in either setting. Conclusions: Drinking behavior was not routinely addressed by medical and mental health practitioners, for dependent and problem-drinking men and women who presented in public and private medical and mental-health settings.

Copyright 2003, Research Society on Alcoholism. Used with permission


Wilson CR; Sherritt L; Gates E; Knight JR. Are clinical impressions of adolescent substance use accurate? Pediatrics 114(5): E536-E540, 2004. (22 refs.)

Objective. To compare providers' impressions of adolescents' level of substance use with diagnostic classifications from a structured diagnostic interview. Methods. Secondary analysis of data was conducted from a validation study of the CRAFFT substance abuse screening test of 14- to 18-year-old medical clinic patients (n = 533) and their corresponding medical care providers (n = 109) at an adolescent clinic affiliated with a large tertiary care pediatric hospital. Medical care providers completed a form that recorded their clinical impressions of patients' level of alcohol and drug involvement (none, minimal, problem, abuse, dependence) and demographic characteristics. The form included brief diagnostic descriptions for each level of use. After the medical visit, patients completed the Adolescent Diagnostic Interview (ADI), a structured diagnostic interview that yields diagnoses of abuse and dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). On the basis of their past 12 months of alcohol and drug use on the ADI interview, adolescents were classified into 5 mutually exclusive diagnostic groups. "None" was defined by no reported use of alcohol or drugs during the past year. "Minimal use" was defined as use of alcohol or drugs but no report of any substance-related problems. "Problem use" was defined as reporting 1 or more substance-related problems but no diagnosis of abuse or dependence. "Abuse" was defined by meeting any 1 of 4 DSM-IV diagnostic criteria for either alcohol or drug abuse but no diagnosis of dependence. "Dependence" was defined by meeting any 3 of 7 diagnostic criteria for either alcohol or drug dependence, with or without a diagnosis of abuse. Proportions were compared using Fisher exact test. Agreement was assessed with the weighted kappa, and these analyses were stratified by substance used (ie, alcohol vs drug) and demographic characteristics. Sensitivity, specificity, and positive and negative predictive values were calculated from 2 x 2 tables. Results. Compared with the criterion standard interview, providers identified significantly fewer patients with problem use and abuse and no patients with dependence. Of >100 patients whom the ADI classified with substance problem use, providers correctly identified 18. Of 50 patients who were classified with a diagnosis of alcohol or drug abuse, providers correctly identified 10. Of 36 patients who were classified with a diagnosis of alcohol or drug dependence, providers correctly identified none. For the 86 adolescents who were classified with a substance-related disorder (ie, abuse or dependence), providers' impressions were "none" (24.4%), "minimal use" (50%), "problem use" (15.1%), "abuse" (10.5%), and "dependence" (0%). There was only marginal agreement between providers' impressions and diagnoses related to alcohol use (kappa = .29), drug use (kappa = .31), and any substance use (kappa = .30). Kappa was not significantly affected by the patient's age, but it was by gender. Among boys, kappa was significantly higher for impressions of drug use versus alcohol use (kappa = .48 vs kappa = .27); and, among drug users, kappa was significantly higher among boys compared with girls (kappa = .48 vs kappa = .24). Kappa did not differ significantly across race/ethnicity subgroups, although there is a suggestive trend toward higher agreement for black non-Hispanic compared with white non-Hispanic adolescents (kappa = .35 vs kappa = .21). Kappa did not differ significantly on the basis of the visit type, but the size of this difference (kappa = .36 vs kappa = .24) suggests that the longer well-child visit yielded greater identification of substance-related pathology. Providers' impressions had a sensitivity of .63 for identifying use of alcohol or drugs. However, sensitivity was poor for identification of problem use (.14), abuse (.10), and dependence (0), whereas specificity and positive predictive values were high. Of the 86 adolescents with a diagnosis of abuse or dependence, 75.6% were correctly identified by providers as using substances; however, the level of use in 50% of these adolescents was reported by providers as minimal. Conclusions. In this study, clinical impressions of adolescents' alcohol/drug involvement underestimated substance-related pathology. When providers thought that use was present, there was a very high likelihood that a problem or disorder existed. The use of structured screening devices would likely improve identification of adolescents with substance-related pathology in primary care settings and should be considered for use with all adolescent patients, rather than only those who are perceived to be at higher risk.

Copyright 2004, American Academy of Pediatrics


Young HE; Rosen CS; Finney JW. A survey of PTSD screening and referral practices in VA addiction treatment programs. Journal of Substance Abuse Treatment 28(4): 313-319, 2005. (33 refs.)

Veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) demonstrate worse outcomes following treatment for SUDs than do veterans with SUDs only, and so PTSD treatment may enhance SUD outcomes for patients. A survey of current practice patterns in VA SUD treatment programs was undertaken to determine their concurrence with emerging practice guidelines for the assessment and treatment of SUD-PTSD comorbidity. Clinicians in outpatient SUD clinics and/or inpatient SUD programs were surveyed in six VA medical centers in 1999 and 2001 (respondents n = 57 and n = 39, respectively). Although one half to two thirds of clinicians working with SUD patients routinely screen for trauma exposure and PTSD, few assessments are systematically conducted using validated measures. Routine referrals to PTSD specialty and dual-diagnosis programs and to veterans' centers are made by between 35% and 60% of providers across inpatient and outpatient settings. Implications for improvement of clinical outcomes are discussed.

Copyright 2005, Elsevier Science Ltd.