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CORK Bibliography: Detection

81 citations. January 2000 to present

Prepared: June 2007

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.

Aalto M; Pekuri P; Seppa K. Primary health care professionals' activity in intervening in patients' alcohol drinking: A patient perspective. Drug and Alcohol Dependence 66(1): 39-43, 2002. (30 refs.)

Aim: To test the hypothesis that primary health care professionals' activity in intervening in patients' alcohol drinking is low. Method: A patient questionnaire Survey after Consultation blind to the primary health care professionals. Subjects were 1000 16-65-year-old consecutive patients consulting a general practitioner. The response rate was 66.5%. Results: Of all participants 6.3% and of excessive drinkers 11.9% were asked about alcohol drinking in the consultation in question. Of all 64.7% and of excessive drinkers 52.4% had never been asked about drinking. Of all 6.0% and of excessive drinkers 19.0% were advised about alcohol drinking at the consultation in question. Conclusion: Alcohol drinking is rarely brought up in discussion by primary health care professionals, even in the case of excessive drinkers.

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.

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.

Angove R; McBride AJ. Swimming upstream: How and why an alcohol misuse screening and intervention service using the AUDIT can have limited impact in primary care. Journal of Substance Use 6(2): 70-79, 2001. (7 refs.)

An alcohol-screening project using the Alcohol Use Disorder Identification Test (AUDIT) was undertaken in several primary healthcare centers in the eastern sector of Cardiff (United Kingdom) in 1997-1998. The project had three aims: (1) to raise awareness of problematic drinking in primary healthcare attenders, (2) to encourage general practitioners to perform brief alcohol education with their patients in addition to laboratory screening, and (3) to offer primary care attenders identified as "alcohol problem very likely" (AUDIT score above 8) a brief motivational interviewing counseling session with the nurse coordinating the project. This article describes the process of implementing the screening and counseling service. Methods of AUDIT questionnaire distribution, reasons given for screening, and cooperation of primary healthcare staff each have an impact on results. When administered anonymously in a pilot project, the AUDIT identified very high rates of problematic drinking. Fifty-eight per cent of all those screening positive had some recorded intervention by their general practitioner, but the majority were highly resistant to further counseling. The views of the primary healthcare staff involved in the project and those patients who attended for counseling are discussed.

Arndt S; Schultz SK; Turvey C; Petersen A. Screening for alcoholism in the primary care setting: Are we talking to the right people? Journal of Family Practice 51(1): 41-46, 2002. (28 refs.)

Background: This study assessed which demographic groups were most likely to consume alcohol excessively, and which groups had received inquiries and discussion about alcohol use from their physicians compared with discussions about other health risks. Study design: This was a cross-sectional study using data from the Centers for Disease Control Behavioral Risk Factors Surveillance System 1997 data set that represents a stratified random sample in the United States. Population We selected 23,349 adults who reported a routine physical examination within the last 3 years. Outcomes measured: The main variables involved responses to questions about alcohol intake and whether the respondent's physician had initiated discussions about drinking. Results Physicians spoke to patients about alcohol use much less frequently than about other health-related behaviors. Discussions were roughly targeted to groups with the largest intake. However, physicians were least likely to speak with white patients, women, and widows who drank significantly. Conclusions: Regularly asking patients about alcohol use could substantially reduce the under-recognition of alcoholism. Since brief counseling is effective, negative consequences of excessive alcohol intake may be avoided.

Averill PM; Veazey C; Shack A; Krajewski D; Rocha D; Varner R. Acute mental illness and comorbid substance abuse: Physician-patient agreement on comorbid diagnosis and treatment implications. Addictive Disorders & Their Treatment 1(4): 119-125, 2002. (19 refs.)

This article examines agreement between physicians and psychiatric inpatients on the presence of comorbid substance abuse. In addition, inpatients with comorbid substance abuse were compared on demographic and diagnostic-related symptoms with those with a single, non-substance-related disorder. Methods: At admission and discharge, 539 patients completed self-report measures of substance use and diagnostic symptoms. Their attending physicians and nurses completed rating scales in the same time frame. In addition, physician discharge diagnoses were examined. Results: For 69% of patients there was agreement between patients and physicians for the absence (30.4%) or presence (38.6%) of substance abuse. For 31%, there was disagreement; 10% were those in whom physicians diagnosed substance abuse but patients denied it, and 21% endorsed substance abuse which their physicians did not diagnose. Also, those who were not substance users tended to receive more severe clinician ratings but self-reported fewer symptoms. They also were more likely to be older, have longer lengths of stay, and to have been admitted involuntarily. Conclusions: A considerable number of psychiatric inpatients are underdiagnosed for comorbid substance abuse. Multimodal means of assessment would probably enhance the inclusion of such diagnoses. Also, differences in symptoms may suggest differences in treatment regimens.

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.

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.

Brathen G; Bjerve KS; Brodtkorb E; Helde G; Bovim G. Detection of alcohol abuse in neurological patients: Variables of clinical relevance to the accuracy of the %CDT-TIA and CDTect methods. Alcoholism: Clinical and Experimental Research 25(1): 46-53, 2001. (42 refs.)

Objectives: Alcohol-related neurological diseases are encountered frequently. Early diagnosis is essential, because minimal intervention effectively reduces hazardous alcohol consumption and may prevent permanent neurological damage. Carbohydrate-deficient transferrin (CDT) is a valuable tool for the identification of alcohol abuse, but for unselected patient populations, reduced test accuracy has been reported. Recently, factors other than alcohol use have been shown to influence CDT levels. Our aim was to identify clinically relevant factors that might reduce test accuracy. Material and Methods: We included 397 neurological patients consecutively hospitalized for seizures, ischemic stroke, or sciatica and 87 patients who attended routine outpatient controls for epilepsy. Blood samples were analyzed for CDT by using two commercially available tests, %CDT-TIA and CDTect. All patients underwent a semistructured clinical interview that included a record of the reported ethanol consumption during the last 8 days, and all completed the Alcohol Use Disorders Identification Test (AUDIT). Current medication, medical history, and demographic information also were obtained. Results: Both tests were elevated in female antiepileptic drug users, compared with others who reported no recent ethanol intake. A higher number of false-positive cases was seen for CDTect than for %CDT. Various combinations of CDT and gamma -glutamyltransferase improved sensitivity, but at the cost of reduced specificity. Variables that predicted the variation of CDT included antiepileptic drug use, sex, body mass index, and smoking. Total transferrin levels were reduced significantly in postmenopausal women, whereas a falling trend was seen for CDTect. Transferrin alterations caused a higher number of false-positive results for CDTect than for %CDT. The area under the receiver operating characteristics curve for women was higher for CDTect than for %CDT, and for %CDT, the area under the receiver operating characteristics curve was higher for men than for women. Conclusion: The accuracy of CDT for detection of alcohol abuse in neurological patients was generally low, particularly for women. Combination variables of CDT and gamma -glutamyltransferase did not increase test accuracy. Variables that were associated with higher CDT levels included female sex, antiepileptic drug use, transferrin alterations, and possibly low body mass index. When factors known to cause poor accuracy in particular patient groups are appreciated, CDT may be a good adjunct to the clinical examination.

Brienza RS; Stein MD. Alcohol use disorders in primary care: Do gender-specific differences exist? (review). Journal of General Internal Medicine 17(5): 387-397, 2002. (142 refs.)

OBJECTIVE: To describe how alcohol use disorders (AUDs) affect women, focusing on gender-specific Implications for primary care physicians (PCPs). DESIGN: An overview of literature from 1966 to 2000 Identified by a MEDLINE, PsychINFO and HealthSTAR/Ovid Healthstar database search using key words "women," "alcohol" and "alcoholism." MEASUREMENTS AND MAIN RESULTS: Although the prevalence of AUDs is greater in men than in women, women with AUDs are more likely to seek help, but less likely to be identified by their physicians. Psychiatric comorbidities (especially depression and eating disorders) are more common in women with AUDs than in men with AUDs. A past history of sexual and/or physical abuse places a woman at Increased risk for AUDs. Women have a greater sensitivity to alcohol, have an accelerated progression from alcohol toxicity, and have increased mortality at lower levels of consumption compared to men. Women and men who are light-to-moderate drinkers have lower coronary artery disease mortality than do abstainers or heavy drinkers. Risk of breast cancer is increased in women who drink greater than or equal to1 drinks daily. Common barriers to treatment include: fear of abandonment by partner; fear of loss of children; and financial dependency. Brief interventions have been shown to be effective in reduction of alcohol consumption in women with at-risk drinking. It is unclear if women-only treatment programs improve outcomes. CONCLUSION: PCPs should be alert to gender-specific differences for women with AUDs.

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.

Cherpitel CJ. Differences in services utilization between white and Mexican American DUI arrestees. Alcoholism: Clinical and Experimental Research 25(1): 122-127, 2001. (25 refs.)

Background: Hispanics traditionally have been considered an underserved population in relation to medical care and related services utilization. Methods: Selected health and social services utilization (both alcohol-specific and non-alcohol-specific) during the last year was compared between a sample of 249 Mexican American (half of whom were born in Mexico) and 250 white participants interviewed in all five DUI (driving under the influence) treatment programs in one northern California county. Results: Among those who met DSM-IV criteria for alcohol dependence and/or alcohol abuse, 49% of the white subjects compared with 59% of the Mexican American subjects reported no utilization, 77% of whites and 82% of Mexican Americans reported no utilization in which drinking was a factor, and 70% of whites and 80% of Mexican Americans reported no contact with an alcohol program. Mexican Americans were also significantly less likely to report contact with more than one program, and among Mexican Americans, those born in Mexico were significantly less likely to report utilization than those born in the U.S. Conclusions: The data suggest that despite the higher rates of heavy drinking found among Mexican American DUI arrestees (especially those born in Mexico) in this sample, Mexican Americans with an alcohol use disorder are less likely to use health and social services than whites, and this may be related to country of birth and related variables that include health insurance. Significance: The data suggest that DUI programs may offer one of the few opportunities Mexican American problem drinkers have of establishing contact with the health and social service system and, as such, would be well positioned to also offer other types of alcohol-related health and social services and referrals to this underserved population. These findings have implications for intervention efforts for problem drinking and prevention of DUI among Mexican Americans, which are a rapidly growing ethnic minority in California.

Colby SM; Barnett NP; Eaton CA; Spirito A; Woolard R; Lewander W et al. Potential biases in case detection of alcohol involvement among adolescents in an emergency department. Pediatric Emergency Care 18(5): 350-354, 2002. (25 refs.)

Objective: To determine the factors associated with physician decisions to test for alcohol involvement in adolescents treated in an emergency department (ED) and to examine patient and event characteristics associated with being identified as alcohol positive, either by testing or by clinical examination. Methods: Medical chart reviews were conducted for all adolescent patients (n = 9660; age range, 13-19 y) treated over a 1-year period in a Level I regional trauma center/ED. Results: Among all 9660 patients in the ED, 298 (3.1 %) were identified as alcohol positive by test or clinical examination. Of the 9660 patients, 464 (4.8 %) were tested for alcohol, and 49 % of these had alcohol-positive test results. Physicians were more likely to order alcohol tests when patients were male, older, injured, and treated during the overnight shift or on weekends. Testing was most common for suicide attempts, motor vehicle crashes, assaults, and intoxication. Patients being treated for an illness or for occupational or athletic injuries were rarely tested. A large proportion of alcohol-related treatment was for intoxicated, uninjured patients, whose profile was different (i.e., younger, more often female, with higher blood alcohol concentrations, and admission distributed more evenly across ED shifts). Conclusions: Case detection rates for alcohol involvement may be biased and inflated when based on physician decisions to test for alcohol use. Rates based on comprehensive chart reviews and clinical examination may be better estimates but are also subject to methodologic limitations. Universal screening would yield the most accurate estimates of alcohol prevalence and would provide more accurate guidance to physicians regarding when to test for alcohol use. Universal screening as a clinical standard would help to identify more adolescents who might benefit from additional alcohol use intervention.

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.

Coogle CL; Osgood NJ; Parham IA. A statewide model detection and prevention program for geriatric alcoholism and alcohol abuse: Increased knowledge among service providers. Community Mental Health Journal 36(2): 137-148, 2000. (36 refs.)

To facilitate the professional development of service providers, the Virginia project on geriatric alcohol abuse and alcoholism developed and used an informational booklet, brochure, and video in a "train the trainer" model. A core group received extensive training, and then trained colleagues in their local communities. Knowledge gains were documented among both trainers and trainees. Follow-up interviews with agency personnel revealed substantial impact on a broad spectrum of service systems and improvements in interagency coordination. Results are discussed in terms of the educational needs of professional service providers regarding the unique aspects of alcoholism and alcohol abuse in the older population.

Coogle CL; Osgood NJ; Parham IA. Follow-up to the statewide model detection and prevention program for geriatric alcoholism and alcohol abuse. Community Mental Health Journal 37(5): 381-391, 2001. (20 refs.)

A follow-up study was conducted to investigate the long term consequences of a statewide geriatric alcoholism detection and prevention effort in Virginia. High levels of knowledge had been retained seven years after the initial training. Quantitative and qualitative data provided by 64 of the volunteers, who were trained to conduct workshops in their communities, verified the program's ability to: 1) encourage further training or study in the area, 2) enhance the detection of alcohol problems, and 3) increase the incidence of assistance to individuals with alcohol problems. Ancillary data revealed the program's effects on personal drinking habits.

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.

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.

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.

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.

Farmer R; Greenwood N. General practitioners' management of problem drinkers: Attitudes, knowledge and practice. Drugs: Education, Prevention and Policy 8(2): 119-129, 2001. (40 refs.)

There is evidence that GPs frequently fail to identify problem drinkers and many are ambivalent about treating them. This study investigated GPs' perceptions of the numbers of their patients with alcohol problems; how they diagnose problem drinkers and their knowledge and attitudes; GPs' perceived roles and part in management. Fifty GPs were interviewed. Reported rates of detection and treatment of problem drinkers were lower than expected, and referral was the most popular management strategy. Screening occurred most frequently at registration or was opportunistic. When characterizing and diagnosing alcohol misuse, GPs emphasized social rather than health or psychological problems. They found it easier to broach the subject of alcohol misuse when there was objective evidence of damage to health. Knowledge of the local alcohol services was good. Although most considered general practice an appropriate place to treat problem drinkers and nearly all believed it was legitimate to inquire about patients' drinking, 70% said they would like more training. Most of the GPs found work with problem drinkers unrewarding, and 40% admitted to not liking drinkers. Complaints of lack of time were frequent. These findings indicate little change since the late 1980s. More GPs appear to be screening patients for problem drinking, but few are themselves treating those identified. GPs need more training and support to manage these patients in general practice but a more realistic appraisal may be required of what GPs themselves can provide.

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.

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.

Friedmann PD; McCullough D; Saitz R. Screening and intervention for illicit drug abuse: A national survey of primary care physicians and psychiatrists. Archives of Internal Medicine 161(2): 248-251, 2001. (25 refs.)

Background: Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse. Methods: We mailed a survey to a national sample of 2000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse. Results: Of 1082 respondents (adjusted response rate, 57%), 68% reported that the) regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that patients will object, and fewer perceived time constraints. Conclusions: Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations.

Garnick DW; Horgan CM; Merrick EL; Hodgkin D; Faulkner D; Bryson S. Managed care plans' requirements for screening for alcohol, drug, and mental health problems in primary care. American Journal of Managed Care 8(10): 879-888, 2002. (43 refs.)

Objective: To determine managed care organizations' (MCOs) requirements for screening for alcohol, drug, or mental health problems in primary care settings. Study Design: A telephone survey was used to gather information on the 3 largest commercial products offered by MCOs. Products included health maintenance organizations, preferred provider organizations, and point-of-service plans. Methods: Managed care organizations were asked whether their products required screening for alcohol, drug, or mental health problems in primary care settings. Chi-square tests were performed to ascertain whether screening requirements, the distribution of practice guidelines, and the topics addressed in those guidelines varied by product type and contracting with specialty behavioral health vendors. The data were weighted to produce national estimates. Results: Only 14.9% of the products surveyed required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half of all the products surveyed distributed practice guidelines that addressed mental illness, and about one third distributed substance abuse practice guidelines. Conclusions: Although the feasibility, utility, and effectiveness of screening are increasingly recognized, few MCOs currently require alcohol, drug, or mental health screening by primary care physicians in any of their product types.

Garnick DW; Lee MT; Chalk M; Gastfriend D; Horgan CM; McCorry F et al. Establishing the feasibility of performance measures for alcohol and other drugs. Journal of Substance Abuse Treatment 23(4): 375-386, 2002. (29 refs.)

Performance measures estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality. Development of performance measures for alcohol and other drug services has lagged behind development of such measures for many other chronic medical conditions, probably because of the unique social role of alcohol and drug use. The Washington Circle (a multiple-disciplinary group of providers, researchers, managed care representatives, and public policy representatives) examined three performance measures for alcohol and other drug (AOD) services. These measures, which were developed and applied to managed care organizations' administrative data for their commercial enrollees, are: (1) identification, the percent of adult enrollees with AOD diagnoses; (2) initiation, the percent of adults with an inpatient AOD admission or with an index outpatient visit for AOD abuse or dependence and any additional AOD services within 14 days of identification; and (3) engagement, the percent of adults diagnosed with AOD disorders that receives two additional AOD services within 30 days of the initiation of care. Results indicated that using administrative databases to compare managed care organizations' performance is feasible, meaningful and informative. This article discusses issues in interpreting performance measures in several areas: organizational structure of alcohol and other drug services, information available for measurement, and computational issues.

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.

Gaughwin M; Dodding J; White JM; Ryan P. Changes in alcohol history taking and management of alcohol dependence by interns at The Royal Adelaide Hospital. Medical Education 34(3): 170-174, 2000. (8 refs.)

Objective: The objective of this study is to determine whether the presence of a drug and alcohol unit and comprehensive medical education have made a difference to the detection and management of alcohol-related problems in a general teaching hospital. Methods Data were obtained from hospital case notes before and after the introduction of the drug and alcohol unit and medical education. Samples of general admissions and admissions with an alcohol diagnosis were obtained. The outcome measures included alcohol history taking, quantification of alcohol consumption and management of alcohol dependence. Results: It was found that for the general admission sample, interns were more likely to take an alcohol history, both in the accident and emergency (A&E) department and on the ward, in 1994 compared to 1988. The difference in the A&E department was statistically significant (P = 0.009). In the A&E department in 1994 there was a greater prevalence of alcohol history taking for male patients (odds ratio (OR) 10.09, 95% confidence interval (CI) 1.89 to 53.70, P = 0.007) compared with female patients (OR = 1.81, 95% CI 0.38 to 8.57, P = 0.045). There were no differences in alcohol history taking by interns in the samples of alcohol-related admissions. There were no statistically significant differences in the prevalence of documenting alcohol histories quantitatively in either sample. The use of alcohol withdrawal charts, ordering diazepam for alcohol withdrawal and ordering drugs which conformed to the hospital formulary all increased significantly by 1994. The prevalence of ordering thiamine and consulting the drug and alcohol unit both decreased slightly by 1994, but not significantly. Conclusion: Improvements have been found in the detection and management of alcohol use since the introduction of the Drug and Alcohol Unit and medical education, but there is still room for further improvement and particular areas where greater attention is needed are identified.

Gomez A; Conde A; Aguiar JA; Santana JM; Jorrin A; Betancor P. Diagnostic usefulness of carbohydrate-deficient transferrin for detecting alcohol-related problems in hospitalized patients. Alcohol and Alcoholism 36(3): 266-270, 2001. (22 refs.)

We evaluated the diagnostic usefulness of carbohydrate-deficient transferrin (CDT) for detecting alcohol-related problems (ARP) in hospitalized patients, assessed potential differences according to gender and age, and compared this value to the other screening measures conventionally used, namely the CAGE questionnaire and standard biological markers MCV (mean corpuscular volume) and GGT (gamma -glutamyltransferase). CDT sensitivity for detecting ARP was 70%, specificity 75% and area under the receiver operating characteristic curve 0.76%. Its sensitivity was shown to be lower both in the female group (65 vs 71%) as well as in the younger-age group whereas its specificity was lower in the liver-damaged group (55%). CDT diagnostic value did not exceed that of CAGE (sensitivity 78% and specificity 99%), MCV (sensitivity and specificity 74%) or GGT (sensitivity 82% and specificity 53%) but was better than those of other biochemical measures. We conclude that CDT is an effective biological marker for the detection of ARP among hospitalized patients, but that its diagnostic usefulness does not exceed that of some other alternative measures commonly used.

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.

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.

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.

Gupman AE; Svikis D; McCaul ME; Anderson J; Santora PB. Detection of alcohol and drug problems in an urban gynecology clinic. Journal of Reproductive Medicine 47(5): 404-410, 2002. (19 refs.)

OBJECTIVE: To compare screening instruments for their utility to detect substance use problems in women seeking gynecologic care, to assess the likelihood that alcohol/drug problems mill be detected by physicians during a routine office visit and to examine the relationship between regular alcohol and/or drug use and the patient's presenting gynecologic complaints. STUDY DESIGN: Women (N = 360) attending a hospital-based gynecology clinic were screened prior to physician visit using the Michigan Alcoholism Screening Test, CAGE and T-ACE. After the visit, information on presenting complaint and physician's documentation of the patient's tobacco, alcohol and other drug use was abstracted from the medical record. RESULTS: The rates of alcohol and illicit drug use varied across assessment instruments; physician documentation, however, yielded the lowest prevalence estimates. Regular alcohol and drug users were more likely to present with chronic and acute medical problems than patients who were not regular users of these substances. CONCLUSION: The gynecology clinic offers an opportunity for early identification of women with substance problems, and alternative strategies are needed to encourage gynecologists to routinely screen for such problems at each medical visit.

Hadida A; Kapur N; Mackway-Jones K; Guthrie E; Creed F. Comparing two different methods of identifying alcohol related problems in the emergency department: A real chance to intervene? Emergency Medicine Journal 18(2): 112-115, 2001. (18 refs.)

Objectives-To examine the feasibility of screening for alcohol problems in a representative flow sample of patients attending a busy UK emergency department. To compare two methods of identifying alcohol related problems in the emergency department. Methods-Brief interview administered by the same interviewer to a representative flow sample of 429 patients attending a single accident and emergency department over a six week period. Measures included a CAGE questionnaire and assessments by the patient and staff as to whether the attendance was alcohol related. Results-413 patients (96%) were successfully screened. Of these, 115 (28%) patients were considered to have an alcohol related attendance on the basis of the CAGE questionnaire or the staff assessment. Head injuries and psychiatric presentations were particularly likely to be associated with alcohol misuse. Compared with those identified by staff, patients scoring above threshold on the CAGE were more likely to attend during routine working hours and recognise they had an alcohol problem. Conclusions-Emergency departments may provide an opportunity for the early prevention of alcohol related difficulties. However, patients with alcohol problems who present to the emergency department are not a homogenous group. Different screening methods identify different groups of patients, who in turn may respond to different forms of intervention. Further research examining the efficacy and feasibility of different alcohol treatment approaches is needed to enable us to target specific interventions to those patients who might most benefit.

Hansen SS; Munk-Jorgensen P; Guldbaek B; Solgard T; Lauszus KS; Albrechtsen N et al. Psychoactive substance use diagnoses among psychiatric in-patients. Acta Psychiatrica Scandinavica 102(6): 432-438, 2000. (32 refs.)

Objective: To estimate the prevalence and possible under-diagnosing of substance use disorders and to consider factors that might influence diagnosing of substance use disorders. Method: Data collected from case records and PSE interviews of psychiatric in-patients from 12 psychiatric departments in Denmark admitted during October 1996 were compared with data from the Danish Psychiatric Register. Results: A substantially lower prevalence of substance use diagnoses were found in the register (26.1%) than in the research data (50.0%). A high prevalence of co-occurrence between substance use disorders and mental disorders other than substance use disorders was found (37.3%). In the majority of cases knowledge of the substance use disorders was present in the case records, although they had not resulted in a diagnosis. Conclusion: The under-diagnosis of substance use disorders is due not only to concealed diagnostic signs and symptoms but also to an underdiagnosis by the psychiatrists, in spite of the fact that information on the substance use was accessible.

Hearne R; Connolly A; Sheehan J. Alcohol abuse: Prevalence and detection in a general hospital. Journal of the Royal Society of Medicine 95(2): 84-87, 2002. (20 refs.)

Despite a high prevalence of alcohol-related disabilities and the availability of cost-effective interventions, alcohol abuse and dependence commonly go undetected in hospital inpatients. In a university teaching hospital we compared three well validated screening methods for sensitivity and specificity-the Alcohol Use Disorders Identification Test (AUDIT, with various cut-off scores), CAGE (a four-question screening tool), and a 10-question version of the Michigan Alcoholism Screening Test (BMAST). A subset of patients also completed the DSM IV structured clinical interview for diagnosis. 1133 adult patients were randomly selected from all hospital admissions, with exclusion of day cases and patients too ill to be interviewed. Two-thirds of the patients were interviewed, most of the remainder being unavailable at the time. 30% of the men and 8% of the women met the DSM IV criteria for alcohol abuse or dependence. Sensitivities and specificities of the screening tools were as follows: AUDIT (with cut-off score > 8) 89% and 91%; CAGE 77% and 99%; BMAST 37% and 100%. 255 case records of patients scoring above the cut-off on one or more questionnaires were subsequently reviewed. The admitting team recognized an alcohol problem in only 46, of whom 17 were referred for appropriate follow up. As in previous hospital surveys, alcohol abuse and dependence was not receiving proper attention. The most efficient screening tool was the CAGE questionnaire.

Hickie IB; Koschera A; Davenport TA; Naismith SL; Scott EM. Comorbidity of common mental disorders and alcohol or other substance misuse in Australian general practice. Medical Journal of Australia 175(Supplement): S31-S36, 2001. (32 refs.)

Objective: To determine in patients attending general practice 1)the extent of comorbidity of mental disorders and alcohol or other substance misuse, and consequent disability; and 2) GPs' diagnosis and management of patients with comorbidity. Design and setting: Cross-sectional national audit of general practices throughout Australia in 1998-1999. Participants: 46515 ambulatory care patients attending 386 GPs. Screening tools: Prevalence of common mental disorders-12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of alcohol or other substance misuse-two self-report screening questions, defining "probable" misuse (a positive response to both questions) and "possible" misuse (a positive response to one of the questions); disability-four items from the Brief Disability Questionnaire, and self-reported "days out of role" and "days in bed" in the past month; and rates of psychological diagnosis, treatment and referral by GPs, and GPs' rating of patients' psychological risk. Main outcome measures: Comorbidity of mental disorders and alcohol or other substance misuse; disability; and correlation with GPs' diagnosis and management. Results: The screening questions revealed possible alcohol or other substance misuse in 11% of patients (5171/46515), and probable misuse in an additional 8% of patients (3593/46515). Comorbidity of mental disorders and substance misuse occurred in 12% (5672/46515) of patients. Patients with comorbidity (compared with those with alcohol or other substance misuse alone) were: more disabled-mean "days out of role in the last month", 8.4 (95% CI, 7.7-9.1) v 3.6 (95% CI, 2.9-4.3); at greater psychological risk (as rated by GPs)-22% v 7%, respectively; more frequently given psychological diagnoses by GPs-51% v 21%; more frequently treated for a psychological condition by GPs-47% v 17%; and more frequently referred to mental health specialists by GPs-9% v 2%. Conclusion: Comorbidity of mental disorders and alcohol or other substance misuse is common in patients attending general practice, and results in considerable disability. Such patients receive inadequate attention (diagnosis and management) from GPs. GPs identifying one of these two types of behaviour disorder in a patient should ascertain whether the other type is also present.

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.

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.

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.

Huntley JS; Blain C; Hood S; Touquet R. Improving detection of alcohol misuse in patients presenting to an accident and emergency department. Emergency Medicine Journal 18(2): 99-104, 2001. (51 refs.)

Objectives-To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback. Setting-An urban accident and emergency department. Subjects-Senior house officers (SHO) (n=13). Outcome measurements-PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT. Results-1062 of 1737 patients (61.1%) were defined as PAT possible- that is, presented with greater than or equal to one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p>0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4),there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall, collapse (including "fit", "blackout"), head injury (including "facial injury"), assault (including "domestic violence" and 'other'), nonspecific gastrointestinal problem, "unwell" , psychiatric (including "depression", "overdose", "confusion"), cardiac (including "chest pain" and "palpitations"), self neglect, repeat attendance. Conclusions-Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

Kelly RH; Zatzick DF; Anders TF. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. American Journal of Psychiatry 158(2): 213-219, 2001. (32 refs.)

Objective: This investigation assessed the detection and treatment of psychiatric disorders and at-risk substance use among pregnant women in the obstetric sector. Method: The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and modified CAGE questionnaires were used to assess current psychiatric disorders and at-risk substance use among 186 women receiving prenatal care. Medical records were reviewed for evidence of obstetrical providers' recognition of psychiatric and substance use symptoms and diagnoses and initiation of evaluations and treatments. The associations between patient characteristics and chart-documented evaluations and treatments were ascertained. Results: Seventy (38%) of the women met screening criteria for psychiatric disorders or substance use. Among women who screened positive, symptoms were recorded in 43% of the charts, diagnoses in 18%, evaluations in 35%, and treatments in only 23% Patients who screened positive for psychiatric disorders and/or substance use were significantly more likely to have a documented mental health evaluation if they were less well educated, had inadequate prenatal care, or had longer hospital stays at delivery. Conclusions: A substantial number of women treated in obstetrics have unrecognized and untreated psychiatric disorders and substance use. Given the potential impact of antenatal mental disturbances on maternal and infant outcomes, further investigations into the psychiatric evaluation and treatment of pregnant women in the obstetrical sector are required.

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.

King RD; Gaines LS; Lambert EW; Summerfelt WT; Bickman L. The co-occurrence of psychiatric and substance use diagnoses in adolescents in different service systems: Frequency, recognition, cost, and outcomes. Journal of Behavioral Health Services & Research 27(4): 417-430, 2000. (44 refs.)

The frequency, severity, recognition, cost, and outcomes of adolescent substance use comorbidity were analyzed in the Fort Bragg Demonstration Project. Comorbidity was defined as the co-occurrence of substance use disorder (SUD) with other psychiatric diagnosis. The sample consisted of 428 adolescent clients whose providers' diagnoses were compared with research diagnoses. The project identified 59 clients (13.8%) with SUD, all with additional psychiatric diagnoses. Providers recognized only 21 of these 59 comorbid cases. The frequency and severity of comorbidity did not differ between service system samples, although recognition did. Comorbid clients had more behavior problems and more functioning impairment, and their average treatment cost ($29,057) was more than twice as high as that of noncomorbid clients ($13,067). Mental health outcomes were not influenced by type of service system, comorbid diagnosis, or treatment. Screening for and prevention of SUD are discussed as a potential cost-savings opportunity in mental health services.

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.

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.

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.

Lahn M; Gallagher EJ; Li SF; Touger M; Olmedo R. Prospective confirmation of low arrest rates among intoxicated drivers in motor vehicle crashes. Academic Emergency Medicine 7(3): 260-263, 2000. (22 refs.)

Objective: Several states have legally sanctioned or mandated physician reporting of drivers who were driving while intoxicated (DWI). Valid prospective evidence demonstrating extremely poor performance of the criminal justice system seems ethically and scientifically essential if overriding public health considerations are to abrogate the fundamental principles of patient-physician confidentiality. No such evidence is available. The authors reasoned that poor performance of the judicial system would be most evident if drivers who were DWI were not arrested under conditions selected to optimize legal intervention. The authors therefore wished to estimate the unbiased proportion of DWI drivers brought to an emergency department (ED) under these optimized conditions who escape detection by law enforcement officials. Methods: Prospective, consecutive cohort of drivers transported to an urban ED following a motor vehicle crash (MVC). Conditions selected to optimize legal intervention included: police at scene; inebriation of driver clinically evident to out-of-hospital personnel; and confirmatory blood ethanol level greater than or equal to 100 mg/dL (greater than or equal to 22 mmol/L). Main outcome measure was arrest for DWI. Results: Of 294 drivers in MVCs, 270 had ethanol levels, of whom 18 met criteria for optimum likelihood of legal intervention. Of these, 22% were arrested for DWI (95% CI = 6% to 48%). Adjustment for missing data, under assumptions designed to maximize arrest frequency for DWI, did not materially alter these findings. No patients were lost to follow-up. Conclusion: These findings prospectively confirm that, even under conditions selected to optimize detection by law enforcement officials, only about one of every five drivers who were DWI and were brought to an ED following an MVC -- and almost certainly no more than a minority -- comes to the attention of the criminal justice system.

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.

Lykouras L; Rontos I; Rontos K; Katsaras A; Markoulis T; Papasteriades E; Christodoulou GN. Detecting alcohol-related problems among general hospital patients with heart disease. Psychotherapy and Psychosomatics 70(1): 25-29, 2001. (25 refs.)

Background: Certain epidemiologic studies suggest that moderate alcohol consumption decreases the risk of coronary heart disease. However, long-term excessive alcohol drinking is considered a major cause for a significant incidence of heart disease. Identifying alcohol-related problems among inpatients with cardiac disease is important. Methods: In this study, 209 male and 137 female inpatients with cardiac disease were screened for alcohol-related problems using the CAGE questionnaire. Associations of alcohol-related problems with sociodemographic and clinical variables were also investigated. Results: Fifty-seven patients (16.5%) scoring positively on the CAGE questionnaire were considered as having alcohol-related problems. Logistic regression analysis revealed that alcohol-related problems were associated with sex (p = 0.00), age (p = 0.0497), and educational level (p = 0,0524). Men less than age 50, with cardiac disease and of lower education level should be considered at high risk for abnormal drinking. The probability increases from 5.2% for the whole sample to 41.9% for the group with these specific characteristics. Conclusions: The characteristics are useful for constructing a profile of the cardiology patient who is more likely to have alcohol-related problems. Early identification and vigorous and holistic treatment of these patients is important for secondary prevention of alcohol-related problems.

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.

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.

Martin MJ; Heymann C; Neumann T; Schmidt L; Soost F; Mazurek B et al. Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract. Alcoholism: Clinical and Experimental Research 26(6): 836-840, 2002. (29 refs.)

Background: Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics. Methods: The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies. Results: By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%. Conclusions. To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.

McQuade WH; Levy SM; Yanek LR; Davis SW; Liepman MR. Detecting symptoms of alcohol abuse in primary care settings. Archives of Family Medicine 9(9): 814-821, 2000. (30 refs.)

Background: Studies on alcohol abuse are frequently based on patients who meet minimum diagnostic criteria, thus ignoring patients with individual symptoms of harmful or hazardous use. Consequently, we are unable to characterize alcohol-abusing patients with sufficient clarity to effectively focus screening for primary prevention. Objective: To determine the prevalence of harmful and hazardous use of alcohol, assess screening instruments for detecting alcohol abuse or dependence, and assess the impact of alcohol use on other diagnoses treated in outpatient settings. Design: Survey (cross-sectional study). Setting: Hospital-based outpatient clinic. Participants: Three hundred randomly selected adults (aged 18 years and older). Main Outcome Measure: Diagnosis of alcohol abuse or dependence based on the Diagnostic Interview Schedule (DIS). Results: About 18% met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria of abuse or dependence while almost 50% had at least one symptom of harmful or hazardous use. The T-ACE questionnaire, a modified version of the CAGE questionnaire, was the most effective screening instrument for both men and women. Selected diagnoses, personal characteristics such as family history of alcohol abuse, and self-reported patterns of alcohol use could identify patients likely to meet diagnostic criteria. Conclusions: Many symptoms of substance use disorders are not adequately addressed in outpatient practice. Little is known about how alcohol use in varying quantities affects health care utilization and treatment of conditions commonly seen in outpatient medicine. Consequently, we lack a full appreciation of the burden of disease borne by alcohol use and have yet to achieve a universally accepted method of approaching primary and secondary prevention of alcohol-related problems.

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.

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.

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.

Patton R; Crawford M; Touquet R. Emergency departments are well placed to identify alcohol misuse problems. (letter). British Medical Journal 324(7332): 300-301, 2002. (5 refs.)

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.

Perrone J; De Roos F; Jayaraman S; Hollander JE. Drug screening versus history in detection of substance use in ED psychiatric patients. American Journal of Emergency Medicine 19(1): 49-51, 2001. (6 refs.)

Because self reporting of substance use may not be reliable, physicians rely on drug screening. We tested the hypothesis that drug screening alone is sufficient to detect substance use in ED psychiatric patients. We prospectively evaluated patients receiving psychiatric consultation over 6 months ending in April 1998 in an urban medical/psychiatric ED with 42,000 annual visits. After informed consent, patients underwent a structured interview by trained research associates who queried regarding substance use in the past 3 days. This self report was compared with urine drug screen results for 11 substances of abuse. Standard descriptive statistical techniques were used. Kappa statistics were used to assess concordance between history and drug screens. Two hundred eighteen patients participated, 124 had a urine drug screen obtained. Patients with and without urine drug screens were similar with respect to age (34.9 Versus 34.9 years, P =.3) and psychiatric diagnosis (P =.24). Overall, there was only fair concordance between history and drug screens (kappa = 0.46). History alone detected substance use in 70 patients (57%); drug screening alone detected substance use in 77 patients (62%), The combination of history and drug screening more often detected substance use than either alone (90 pts (73%); P <.05 for both comparisons). Depending on the particular drug, there was wide variation in concordance between history and drug screen (kappa's varied from 0.07 for ethanol to 0.79 for cocaine). History was better than drug screening for ethanol use (40 versus 10 patients), and THC (28 versus 15 pts). Drug testing alone was never significantly better than history. Although self-reporting of substance use is not reliable, reliance on drug screening alone is also flawed. Optimal identification of drug use in emergency department psychiatric patients requires both history and drug screening.

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.

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] a 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.

Reynaud M; Schwan R; Loiseaux-Meunier MN; Albuisson E; Deteix P. Patients admitted to emergency services for drunkenness: Moderate alcohol users or harmful drinkers? American Journal of Psychiatry 158(1): 96-99, 2001. (37 refs.)

Objective: Most of the patients admitted to hospital emergency services are drunk. Some of them may need specific treatment after acute intoxication remits. At present, treatment for alcoholism is offered to less than 5% of these patients. The authors evaluated the biological markers carbohydrate-deficient transferrin (CDT) and gamma -glutamyltransferase (GGT) in patients admitted for acute alcohol intoxication (per DSM-IV criteria) supported by blood alcohol assay. These tests distinguished between otherwise moderate alcohol users who were acutely intoxicated and harmful drinkers or alcohol- dependent patients. Method: The authors conducted an exhaustive survey 24 hours a day during 2 nonconsecutive months. The study involved 166 patients (124 men and 42 women) who were admitted for acute alcohol intoxication as a principal or additional diagnosis. Their blood was analyzed for alcohol, GGT, and CDT levels. The CAGE questionnaire was administered, and social and demographic data were collected. Results: About 80% of the population studied displayed elevated GGT or CDT levels (65.7% had CDT levels >60 mg/liter; 41.6% had GGT levels >65 IU/liter). Less than 10% of the patients with acute alcohol intoxication revealed results in the normal range for both markers and a negative finding on the CAGE questionnaire. Conclusions: Patients admitted to emergency services with high blood alcohol levels should not be assumed to be moderate drinkers. Any drunkenness should be interpreted as a sign of likely harmful alcohol consumption or alcohol dependency requiring clinical and biological tests, including CCT and CDT assays. Specific treatment for alcoholism should be systematically offered to these patients.

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.

Roeloffs CA; Fink A; Unutzer J; Tang LQ; Wells KB. Problematic substance use, depressive symptoms, and gender in primary care. Psychiatric Services 52(9): 1251-1253, 2001. (10 refs.)

This study determined the frequency of problematic substance use and of counseling about drug and alcohol use among 867 women and 320 men who reported symptoms of depression in managed primary care clinics. Seventy-two (8.3 percent) of the women and 61 (19 percent) of the men reported hazardous drinking; 228 (26.3 percent) of the women and 94 (29.4 percent) of the men reported problematic drug use, including use of illicit drugs and misuse of prescription drugs. Only 17 (13.9 percent) of the patients who reported hazardous drinking and 18 (6.6 percent) of those who reported problematic drug use received counseling about drug or alcohol use during their last primary care visit. Men were significantly more likely than women to have received counseling about drug or alcohol use from their primary care practitioner.

Rumpf HJ; Bohlmann J; Hill A; Hapke U; John U. Physicians' low detection rates of alcohol dependence or abuse: A matter of methodological shortcomings? General Hospital Psychiatry 23(3): 133-137, 2001. (24 refs.)

Previous research may have underestimated physicians' detection rates of alcohol dependence or abuse because case findings have been based on screening questionnaires instead of using in-depth diagnostic criteria and detection rates have been assessed by analyzing patient records instead of directly interviewing the physician. To test this hypothesis, consecutive patients of a general hospital (N=436) and of 12 randomly selected general practices (N=929) were examined. A two- step diagnostic procedure included screening questionnaires and a diagnostic interview (SCAN). The analysis compares detection rates based on methods used in previous studies to data using more precise methods. Physicians' detection rates ranged from 37.0% to 88.9% in the general hospital and from 11.1% to 74.7% in general practices depending on methods used. The physicians' detection rates could be improved by 10% (general hospital) and 20% (general practice) through the additional use of a screening questionnaire. Of those patients assessed by the physicians as problem drinkers in the general hospital, 13.9% were referred to an addiction consultation-liaison service. Data reveal that physicians' abilities to detect problem drinkers have been underestimated. Routine screening procedures could play a major role in improving detection rates and reminding the physician to intervene.

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.

Schneekloth TD; Morse RM; Herrick LM; Suman VJ; Offord KP; Davis LJ Jr. Point prevalence of alcoholism in hospitalized patients: Continuing challenges of detection, assessment, and diagnosis. Mayo Clinic Proceedings 76(5): 460-466, 2001. (35 refs.)

Objective: To measure a 1-day point prevalence of alcohol dependence among hospitalized patients and to assess practices of detection, evaluation, and diagnosis of alcohol problems. Patients and Methods: On April 27, 1994, a total of 795 adult inpatients at 2 Midwestern teaching hospitals were asked to complete a survey that included the Self-administered Alcoholism Screening Test (SAAST). The records of SAAST-positive patients were reviewed to determine the numbers of patients receiving laboratory screening for alcoholism, addiction consultative services, and a discharge diagnosis of alcoholism. Results: The survey response rate was 84% (667/795). Of the 569 patients who provided SAAST information, 42 (7.4%) had a positive SAAST score and thus were identified as alcohol dependent. Thirteen (31%) of the 42 alcoholic patients received addiction or psychiatric consultative services during their hospitalization. Serum gamma - glutamyltransferase was measured in 4 (11%) of the 38 actively drinking alcoholic patients. Three (7%) of 42 alcoholic patients received a discharge diagnosis of alcohol abuse or dependence. Conclusions: The alcoholism prevalence rate was lower than those observed in several other US hospitals. Laboratory testing may be underutilized in identifying hospitalized patients who may be addicted to alcohol. Physician use of consultative services and diagnosis of alcohol dependence had not improved from similar observations more than 20 years earlier. These findings may indicate persistent problems in physician detection, assessment, and diagnosis of alcoholism.

Sillanaukee P; Kaariainen J; Sillanaukee P; Poutanen P; Seppa K. Substance use-related outpatient consultations in specialized health care: An underestimated entity. Alcoholism: Clinical and Experimental Research 26(9): 1359-1364, 2002. (32 refs.)

Background: To study the occurrence and documentation of substance use related outpatient visits in, specialized health care. Methods: The diagnosis recorded in retrospective discharge data in Tampere University Hospital for 6 years was compared with the prospective data gathered from separately completed forms added during an 8-week period to every outpatient's discharge data. In this form, the relation of substance use and the actual reason for the consultation were specifically elicited. Results: On the basis of diagnoses, retrospectively, 0.4% (6,666 of 1,555,898) of outpatient visits were caused by substance use: In the prospective part of the study, 5.6% of visits (1,401/25,014) were related to substance use. Retrospective study demonstrated 2% prevalence of substance use, whereas prospective study showed 36% substance use-related visits at the emergency room. According to the retrospective discharge data, alcohol-related organ damages were the major reason for substance use-related outpatient visits. In the prospective study, the proportion of acute traumas was most prevalent. Conclusions: Our study indicates that substance use-related visits often remain undetected in specialized health care. Substance use-related visits were under documented/undetected in the emergency room. Using a simple separate form could dramatically increase the detection of substance use-related visits.

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.

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.

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.

Walkup JT; McAlpine DD; Olfson M; Labay L; Boyer CA; Hansell S. Is the substance abuse of inpatients with schizophrenia overlooked? General Hospital Psychiatry 23(1): 26-30, 2001. (31 refs.)

The utility of medical records and clinician reports for assessing substance abuse among inpatients with schizophrenia or schizoaffective disorder was assessed in a sample of 296 patients recruited from four general hospitals in New York City. Measures derived from the medical record, the discharge summary, and primary clinician reports are compared to the