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CORK Bibliography: Primary Care

125 citations. January 2012 to present

Prepared: June 2012

Allensworth-Davies D; Cheng DM; Smith PC; Samet JH; Saitz R. The Short Inventory of Problems modified for Drug Use (SIP-DU): Validity in a primary care sample. American Journal on Addictions 21(3): 257-262, 2012. (17 refs.)

Primary care physicians can help drug-dependent patients mitigate adverse drug use consequences; instruments validated in primary care to measure these consequences would aid in this effort. This study evaluated the validity of the Short Inventory of Problems Alcohol and Drugs modified for Drug Use (SIP-DU) among subjects recruited from a primary care clinic (n= 106). SIP-DU internal consistency was evaluated using Cronbach's alphas, convergent validity by correlating the total SIP-DU score with the DAST-10, and construct validity by analyzing the factor structure. The SIP-DU demonstrated high internal consistency (Cronbach's alpha for overall scale .95, subscales .72.90) comparable with other SIP versions and correlated well with the DAST-10 (r= .70). Confirmatory factor analysis suggested an unacceptable fit of previously proposed factors; exploratory factor analyses suggested a single factor of drug use consequences. The SIP-DU offers primary care clinicians a valid and practical assessment tool for drug use consequences.

[Anonymous]. Addiction medicine and substance abuse care. (editorial). Canadian Family Physician 57(11): e429-e429, 2011. (1 refs.)

Asfar T; Al-Ali R; Ward KD; Vander Weg MW; Maziak W. Are primary health care providers prepared to implement an anti-smoking program in Syria? Patient Education and Counseling 85(2): 201-205, 2011. (60 refs.)

Objective: To document primary health care (PHC) providers' tobacco use, and how this influences their smoking cessation practices and attitudes towards tobacco-control policies. Methods: Anonymous questionnaires were distributed to PHC providers in 7 randomly selected PHC centers in Aleppo, Syria. Results: All PHC providers completed the questionnaires (100% response rate). A quarter of these providers smoke cigarettes and more than 10% smoke waterpipes. Physicians who smoke were less likely to advise patients to quit (OR = 0.29; 95% CI, 0.09-0.95), assess their motivation to quit (OR = 0.13, 95% Cl = 0.02-0.72), or assist them in quitting (OR = 0.24, 95% CI = 0.06-0.99). PHC providers who smoke were less likely to support a ban on smoking in PHC settings (68.2% vs. 89.1%) and in enclosed public places (68.2% vs. 86.1%) or increases in the price of tobacco products (43.2% vs. 77.4%) (P<0.01 for all comparisons). Conclusions: Smoking, including waterpipe, continues to be widespread among PHC providers in Syria and will negatively influence implementation of anti-smoking program in PHC settings. Practice implications: Smoking awareness and cessation interventions targeted to PHC providers, and training programs to build providers' competency in addressing their patients' smoking is crucial in Syria.

Becker WC; Starrels JL; Heo M; Li X; Weiner MG; Turner BJ. Racial differences in primary care opioid risk reduction strategies. Annals of Family Medicine 9(3): 219-225, 2011. (46 refs.)

PURPOSE: Racial disparities in treating pain with opioids are widely reported; however, differences in use of recommended strategies to reduce the risk of opioid misuse by race/ethnicity have not been evaluated. METHODS: In a retrospective cohort of black and white patients with chronic noncancer pain prescribed opioid analgesics for at least 3 months, we assessed physicians' use of 3 opioid risk reduction strategies: (1) urine drug testing, (2) regular office visits (at least 1 visit per 6 months on opioids and within 30 days of an opioid change), and (3) restricted early opioid refills (receipt of a refill >1 week early less than twice). Nonlinear mixed effect regression models accounted for clustering within physician and adjusted additively for demographics, substance abuse, mental health and medical comorbidities, health care factors, and practice site. RESULTS: Of the 1,612 patients studied, 62.1% were black. Black patients were more likely than white patients to receive urine drug testing (10.4% vs 4.1%), regular office visits (56.4% vs 39.0%), and restricted early refills (79.4% vs 72.0%) (P <.001 for each). In fully adjusted models, black patients had significantly higher odds than their white counterparts of receiving regular office visits (odds ratio = 1.51; 95% confidence interval, 1.06-2.14) and restricted early refills (odds ratio = 1.55; 95% confidence interval, 1.03-2.32), but not urine drug testing (odds ratio = 1.41; 95% confidence interval, 0.78-2.54). CONCLUSIONS: In this cohort of primary care patients receiving opioid analgesics on a long-term basis, use of risk reduction strategies was very limited overall; however, black patients were more likely than white patients to receive 2 of 3 guideline-recommended strategies. These data raise questions about lax monitoring, especially for white patients taking opioids long term.

Blix HS; Hjellvik V; Litleskare I; Ronning M; Tverdal A. Cigarette smoking and risk of subsequent use of antibacterials: A follow-up of 365,117 men and women. Journal of Antimicrobial Chemotherapy 66(9): 2159-2167, 2011. (40 refs.)

Objectives: Antibacterial prescribing is driving antibiotic resistance. We aimed to analyse whether smoking habits are associated with susceptibility to be prescribed antibacterials in primary care and to examine whether patients' smoking habits influence physicians' choice of therapy. Methods: Information on smoking habits from health surveys in 1985-99 was related to use of antibacterials 5-25 years later by linkage to the Norwegian Prescription Database. The study population included 365117 men and women, 40-45 years old. Individuals likely to have chronic obstructive airway disease were excluded. Relative risk (RR) of being dispensed antibacterials for systemic use was calculated for five levels of smoking intensity with never smokers as reference. Adjustments were made for age, education, marital status, household size, body mass index and residence (rural/urban). Results: Fifty-six percent of the male and 69% of the female never smokers received at least one antibacterial prescription in the whole period, increasing to 68% and 82%, respectively, in heavy smokers (>19 cigarettes/day) (adjusted RR 1.17 and 1.16). The percentage receiving at least one antibacterial prescription every year was 0.5% in male and 1.9% in female never smokers, increasing to 1.1% and 4.0%, respectively, in heavy smokers (adjusted RR 2.07 and 1.89). The proportion of antibacterial users who were prescribed broad-spectrum antibacterials increased with increasing cigarette consumption. Conclusions: Smoking habits influenced the usage of antibacterials years later with a dose-response relationship. Prescribers seem to acknowledge smoking as a risk factor for resistant bacteria since broad-spectrum antibacterials are more frequently prescribed to smokers than never smokers.

Bradley KA; Johnson ML; Williams EC. Commentary on Nilsen et al. (2011): The importance of asking patients. The potential value of patient report of brief interventions (editorial). Addiction 106(10): 1757-1759, 2011. (19 refs.)

Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011. (Chapter refs.)

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. Part I sets forth basic constructs of addiction medicine. This includes discussion of the disease concept, abstinence as a treatment goal, medical sequelae of addiction, the relationship of substance use and suicide. psychotherapeutic paradigms, and drug therapies. Part II focuses upon "the real world." It includes twelve step approaches; nicotine addiction and smoking cessation; managing alcoholism in primary care; methadone treatment; prescription drug abuse. Part III considers special topics, such as pain management and addiction treatment; neurofeedback; drug therapies for alcohol dependence; emergency medical presentation; acupuncture; and EEG neurofeedback therapy.

Brose LS; West R; McDermott MS; Fidler JA; Croghan E; McEwen A. What makes for an effective stop-smoking service? Thorax 66(10): 924-926, 2011. (7 refs.)

Background: The English network of stop-smoking services (SSSs) is among the best-value life-preserving clinical intervention in the UK NHS and is internationally renowned. However, success varies considerably across services, making it important to examine the factors that influence their effectiveness. Methods: Data from 126 890 treatment episodes in 24 SSSs in 2009-10 were used to assess the association between intervention characteristics and success rates, adjusting for key smoker characteristics. Treatment characteristics examined were setting (eg, primary care, specialist clinics, pharmacy), type of support (eg, group, one-to-one) and medication (eg, varenicline, single nicotine replacement therapy (NRT), combination of two or more forms of NRT). The main outcome measure was abstinence from smoking 4 weeks after the target quit date, verified by carbon monoxide concentration in expired air. Results: There was substantial variation in success rates across intervention characteristics after adjusting for smoker characteristics. Single NRT was associated with higher success rates than no medication (OR 1.75, 95% CI 1.39 to 2.22); combination NRT and varenicline were more successful than single NRT (OR 1.42, 95% CI 1.06 to 1.91 and OR 1.78, 95% CI 1.57 to 2.02, respectively); group support was linked to higher success rates than one-to-one support (OR 1.43, 95% CI 1.16 to 1.76); primary care settings were less successful than specialist clinics (OR 0.80, 95% CI 0.66 to 0.99). Conclusions: Routine clinic data support findings from randomised controlled trials that smokers receiving stop-smoking support from specialist clinics, treatment in groups and varenicline or combination NRT are more likely to succeed than those receiving treatment in primary care, one-to-one and single NRT. All smokers should have access to, and be encouraged to use, the most effective intervention options.

Brown RL. Configuring health care for systematic behavioral screening and intervention. Population Health Management 14(6): 299-305, 2011. (58 refs.)

The United States Preventive Services Task Force recommends universal screening and intervention for tobacco use, excessive drinking, and depression. These services improve health outcomes, decrease health care costs, enhance public safety, and generate substantial return on investment. Given the prevalence rates of these behavioral conditions and the time necessary for evidence-based interventions, it will be challenging to integrate behavioral screening and intervention (BSI) into busy health care settings. Therefore, consistent with the principles of the medical home and the chronic care model, the health care team must be expanded to systematically provide BSI. A 2-tiered, stepped-care model is proposed. The first tier of services-consisting of assessment, intervention, and follow-up services-would address most mild-to-moderate behavioral risks or conditions. The second tier would include various specialty-based resources, which would be conserved for patients with greatest need and potential to benefit. With slight enhancement of their training, health educators would be excellent candidates to serve as cost-efficient providers of first-tier services. The proposed model would help the United States realize improved health outcomes and cost savings as health care benefits are expanded to a greater proportion of its population.

Bruce RD. One stop shopping - Bringing services to drug users. (editorial). International Journal of Drug Policy 23(2): 104-104, 2012. (1 refs.)

Cabezas C; Advani M; Puente D; Rodriguez-Blanco T; Martin C; ISTAPS Study Group. Effectiveness of a stepped primary care smoking cessation intervention: Cluster randomized clinical trial (ISTAPS study). Addiction 106(9): 1696-1706, 2011. (49 refs.)

Aim: To evaluate the effectiveness in primary care of a stepped smoking cessation intervention based on the trans-theoretical model of change. Design Cluster randomized trial; unit of randomization: basic care unit (family physician and nurse who care for the same group of patients); and intention-to-treat analysis. Setting All interested basic care units (n = 176) that worked in 82 primary care centres belonging to the Spanish Preventive Services and Health Promotion Research Network in 13 regions of Spain. Participants A total of 2827 smokers (aged 14-85 years) who consulted a primary care centre for any reason, provided written informed consent and had valid interviews. Measurements: The outcome variable was the 1-year continuous abstinence rate at the 2-year follow-up. The main variable was the study group (intervention/control). Intervention involved 6-month implementation of recommendations from a Clinical Practice Guideline which included brief motivational interviews for smokers at the precontemplation-contemplation stage, brief intervention for smokers in preparation-action who do not want help, intensive intervention with pharmacotherapy for smokers in preparation-action who want help and reinforcing intervention in the maintenance stage. Control group involved usual care. Among others, characteristics of tobacco use and motivation to quit variables were also collected. Findings The 1-year continuous abstinence rate at the 2-year follow-up was 8.1% in the intervention group and 5.8% in the control group (P = 0.014). In the multivariate logistic regression, the odds of quitting of the intervention versus control group was 1.50 (95% confidence interval = 1.05-2.14). Conclusions: A stepped smoking cessation intervention based on the transtheoretical model significantly increased smoking abstinence at a 2-year follow-up among smokers visiting primary care centres.

Carlsten C; Halperin A; Crouch J; Burke W. Personalized medicine and tobacco-related health disparities: Is there a role for genetics? (editorial). Annals of Family Medicine 9(4): 366-371, 2011. (69 refs.)

Genetic testing has been proposed as a means to increase smoking cessation rates and thus reduce smoking prevalence. To understand how that might be practically possible, with appreciation of the current social context of tobacco use and dependence, we performed a contextual analysis of smoking-related genetics and smoking cessation. To provide added value, genetics would need to inform and improve existing interventions for smokers (including behavioral and pharmacological treatments). Pharmacogenetics offers the most promising potential, because it may improve the efficacy of medication-based smoking cessations strategies. All proven interventions for treating tobacco dependence, however, including simple cost-effective measures, such as quit lines and physician counseling, are underutilized. As tobacco use occurs disproportionately among disadvantaged populations, efforts to improve smokers' access to health care, and to the tools that are known to help them quit, represent the most promising approaches for reducing smoking prevalence within these groups. Similar considerations apply to other chronic diseases contributing to population-level health disparities. We conclude that although genetics offers increasing opportunities to tailor drug treatment, and may in some cases provide useful risk prediction, other methods of personalizing care are likely to yield greater benefit to populations experiencing health disparities related to tobacco use.

Chavez LJ; Williams EC; Lapham G; Bradley KA. Association between alcohol screening scores and alcohol-related risks among female Veterans Affairs patients. Journal of Studies on Alcohol and Drugs 73(3): 391-400, 2012. (59 refs.)

Objective: Evidence-based brief interventions for primary care patients with at-risk drinking include personalized feedback on alcohol-related risks, yet little is known about associations between alcohol screening scores and outcomes among women. This study evaluated associations between scores on the three-item Alcohol Use Disorders Identification Test consumption (AUDIT-C) questionnaire and self-reported alcohol-related risks and consequences among veteran women. Method: Female outpatients from an urban Veterans Affairs facility were mailed annual surveys (1998-2000) (response rates: 65% Years 1 and 2, 55% Year 3). Measures were obtained from each respondent's first completed survey and included a gender-specific AUDIT-C (0-12 points), self-reported alcohol-related consequences, problem drinking or other drug use, and health risks. The prevalence of each outcome across AUDIT-C score groups (0, 1-2, 3, 4, 5-7, 8-12) was estimated using logistic regression, adjusting for age, race, and marital status. Results: Among 2,670 respondents, 23.7% screened positive for alcohol misuse (AUDIT-C >= 3). For three out of the five alcohol-related consequences (tolerance, blackouts, felt needed to cut down), adjusted prevalence increased at AUDIT-C scores of 3 or more. The remaining alcohol-related consequences (morning eye openers, family/friends worried) increased at scores of 4 or more, as did self-reported problem drinking or other drug use. Associations between health risks (two or more sexual partners, sexually transmitted diseases, injuries, domestic violence, hepatitis/cirrhosis) and AUDIT-C scores were less consistent, but prevalence generally increased at scores of 5 or more. Conclusions: Increasing scores on the AUDIT-C reflect increasing prevalence of self-reported alcohol-related risks and consequences among women. These results provide clinicians with gender-specific information on alcohol-related risks that could be incorporated into brief interventions.

Chellini E; Gorini G; Carreras G; Giordano L; Anghinoni E; Iossa A et al. The Pap smear screening as an occasion for smoking cessation and physical activity counselling: Baseline characteristics of women involved in the SPRINT randomized controlled trial. BMC Public Health 11: article 906, 2011. (29 refs.)

Background: Gender-specific smoking cessation strategies have rarely been developed. Evidence of effectiveness of physical activity (PA) promotion and intervention in adjunct to smoking cessation programs is not strong. SPRINT study is a randomized controlled trial (RCT) designed to evaluate a counselling intervention on smoking cessation and PA delivered to women attending the Italian National Health System Cervical Cancer Screening Program. This paper presents study design and baseline characteristics of the study population. Methods/Design: Among women undergoing the Pap examination in three study centres (Florence, Turin, Mantua), participants were randomized to the smoking cessation counselling [S], the smoking cessation + PA counselling [S + PA], or the control [C] groups. The program under evaluation is a standard brief counselling on smoking cessation combined with a brief counselling on increasing PA, and was delivered in 2010. A questionnaire, administered before, after 6 months and 1 year from the intervention, was used to track behavioural changes in tobacco use and PA, and to record cessation rates in participants. Discussion: Out of the 5,657 women undergoing the Pap examination, 1,100 participants (55% of smokers) were randomized in 1 of the 3 study groups (363 in the S, 366 in the S + PA and 371 in the C groups). The three arms did not differ on any demographic, PA, or tobacco-use characteristics. Recruited smokers were older, less educated than non-participant women, more motivated to quit (33% vs. 9% in the Preparation stage, p < 0.001), smoked more cigarettes per day (12 vs. 9, p < 0.001), and were more likely to have already done 1 or more quit attempts (64% vs. 50%, p < 0.001). The approach of SPRINT study appeared suitable to enrol less educated women who usually smoke more and have more difficulties to quit.

Cheng D; Patel P. Optimizing women's health in a Title X family planning program, Baltimore County, Maryland, 2001-2004. Preventing Chronic Disease 8(6): article A126, 2011. (14 refs.)

Background: Although women usually obtain family planning services during their reproductive years, their need for comprehensive preventive services that promote wellness beyond reproductive health is often ignored. Community Context: The Maryland Department of Health and Mental Hygiene sought to improve the general health of women and reduce their risk for adverse pregnancy outcomes by integrating women's health services into the Baltimore County Title X program. Title X is a federal family planning grant program primarily serving low-income, uninsured people. Methods: After completing a needs assessment, we addressed gaps in women's wellness services in 3 family planning clinics. On-site services included counseling, screening, and referral for nutrition and physical activity, adult vaccination, depression, domestic violence, smoking cessation, substance abuse, and general medical disorders. A local multidisciplinary task force provided leadership for the clinical infrastructure of the project and served as a resource for women's health referrals. Outcome: Every staff person surveyed reported that the project had a positive effect on the community and should be continued. Clients identified non-reproductive health services they needed but would not have received otherwise. During the 3-year period, patient volume increased 28% for the pilot sites, compared to 1% for the state family planning program overall. Interpretation: With collaboration from a multidisciplinary community task force, the Title X family planning program can help provide needed preconception, interconception, and general women's health services, especially for women who have difficulty accessing care.

Chi FW; Parthasarathy S; Mertens JR; Weisner CM. Continuing care and long-term substance use outcomes in managed care: Early evidence for a primary care-based model. Psychiatric Services 62(10): 1194-1200, 2011. (44 refs.)

Objectives: How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry. Methods: In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure. Results: A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without. Conclusions: Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

Collet TH; Salamin S; Zimmerli L; Kerr EA; Clair C; Picard-Kossovsky M et al. The quality of primary care in a country with universal health care coverage. Journal of General Internal Medicine 26(7): 724-730, 2011. (39 refs.)

BACKGROUND: Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage. OBJECTIVE: To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage. DESIGN AND PARTICIPANTS: Retrospective cohort of a random sample of 1,002 patients aged 50-80 years followed for 2 years from all Swiss university primary care settings. MAIN MEASURES: We used indicators derived from RAND's Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator. KEY RESULTS: Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including > 75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients < 65 years (70.1% vs 68.0% in those a parts per thousand yen65 years, p = 0.047). CONCLUSIONS: Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.

Cousins G; Teljeur C; Motterlini N; McCowan C; Dimitrov BD; Fahey T. Risk of drug-related mortality during periods of transition in methadone maintenance treatment: A cohort study. Journal of Substance Abuse Treatment 41(3): 252-260, 2011. (38 refs.)

This study aims to identify periods of elevated risk of drug-related mortality during methadone maintenance treatment (MMT) in primary care using a cohort of 3,162 Scottish drug users between January 1993 and February 2004. Deaths occurring during treatment or within 3 days after last methadone prescription expired were considered as cases "on treatment." Fatalities occurring 4 days or more after leaving treatment were cases "off treatment." Sixty-four drug-related deaths were identified. The greatest risk of drug-related death was in the first 2 weeks of treatment (adjusted hazard ratio 2.60, 95% confidence interval 1.03-6.56). Risk of drug-related death was lower after the first 30 days following treatment cessation, relative to the first 30 days off treatment. History of psychiatric admission was associated with increased risk of drug-related death in treatment. Increasing numbers of treatment episodes and urine testing were protective. History of psychiatric admission, increasing numbers of urine tests, and coprescriptions of benzodiazepines increased the risk of mortality out of treatment. The risk of drug-related mortality in MMT is elevated during periods of treatment transition, specifically treatment initiation and the first 30 days following treatment dropout or discharge.

Cox LS; Cupertino AP; Tercyak KP. Interest in participating in smoking cessation treatment among Latino primary care patients. Journal of Clinical Psychology In Medical Settings 18(4): 392-399, 2011. (42 refs.)

Smoking is the leading preventable cause of disease and death for U.S. Latinos. This study identified correlates of interest in participating in a smoking cessation program among urban Latinos seen in community clinics. Interviews were completed with 141 current smokers. Participants were predominantly Spanish-speaking (93%) males (66%), who were on average 37.6 years old and smoked 8.7 cigarettes per day. Over two-thirds (63%) of participants were "definitely interested" in participating in a smoking cessation program. Participants who smoked more cigarettes per day and reported greater nicotine dependence, depression, and readiness to quit were more likely to be interested, while those employed fulltime were less likely to report high interest. Treatment preferences were consistent with Clinical Practice Guidelines recommending counseling, social support, and pharmacotherapy. Results support recommendations that healthcare providers intervene with all Latino smokers, including light smokers and those who do not report initial interest in smoking cessation.

de Wit M; Zilberberg MD; Boehmler JM; Bearman GM; Edmond MB. Outcomes of patients with alcohol use disorders experiencing healthcare-associated infections. Alcoholism: Clinical and Experimental Research 35(7): 1368-1373, 2011. (48 refs.)

Background: Healthcare-associated infections (HAI) affect 1.7 million patients annually in the United States, and patients with alcohol use disorders (AUD) are at increased risk of developing HAI. HAI have been shown to substantially increase the hospital length of stay, mortality, and cost. In a cohort of patients with HAI, we sought to determine mortality, cost, and hospital length of stay attributable to AUD. Methods: Using the Nationwide Inpatient Sample for the year 2007, the largest all-payer database of hospitalized patients comprising approximately 1,000 hospitals, we performed a retrospective cohort study of all patients who developed healthcare-associated pneumonia or sepsis. We excluded patients who were transferred from another healthcare facility, who were diagnosed with community-acquired infections, immunosuppression, or cancer. Logistic regression was computed to calculate attributable mortality. Linear regression analyses were computed to determine cost and hospital length of stay alpha - 10(-10). Results: A total of 149,892 patients developed HAI, and 8,830 (5.9%) had a codiagnosis of AUD. Patients with AUD were younger, more likely to be men, less likely to be Asian, and more likely to be Hispanic. Patients with AUD were more likely to have tobacco dependence, less likely to be electively admitted to the hospital, and less likely to undergo surgery. They also had lower severity of illness, lower income, and were more likely to be in academic medical centers. Logistic regression revealed that AUD was an independent predictor of increased mortality: Odds ratio = 1.71, 95% confidence interval (CI) [1.626; 1.799], p < 10(-10). Linear regression demonstrated that AUD independently predicted increased hospital length of stay by 2 days: Patients with AUD had a length of stay of 13 days, 95% CI [12.4; 13.6] compared with 11 days, 95% CI [11.1; 11.4] for patients without AUD, p < 10(-10). Linear regression also revealed that patients with AUD had a higher hospital cost: $ 34,826, 95% CI [32,415.71; 37,416.52] for patients with AUD compared with $ 27,167, 95% CI [25,703.18; 28,714.05] for patients without AUD, p < 10(-10). Conclusions: Patients with AUD who experience HAI have worse outcomes compared with patients without AUD. Patients with AUD have higher mortality, longer hospital length of stay, and higher costs. Studies aimed at decreasing the morbidity and mortality of HAI in patients with AUD are warranted.

deGruy FV; Etz RS. Attending to the whole person in the patient-centered medical home: The case for incorporating mental healthcare, substance abuse care, and health behavior change. Families, Systems & Health 28(4): 298-307, 2010. (23 refs.)

The foundation of the U.S. healthcare system is faulty, and the consequences have become inescapable (Committee of Quality of Health Care in America, 2001). We are first among nations in spending on healthcare, whether measured in absolute dollars, per capita expenditures, or proportion of our national budget. Yet our citizens are the least healthy in the developed world. (Anderson & Hussey, 2001) Our nation's healthcare system is simply not a high-quality system. This shortfall is serious enough to cause tens of thousands of unnecessary deaths each year and to compromise our capacity for further economic growth (Anderson & Hussey, 2001; Anderson, Frogner, Johns, & Reinhardt, 2006; Macinko, Starfield, & Shi, 2003), yet it ramifies into so many of our political, financial, and social institutions that change is difficult and fraught with serious unintended consequences.

Demirkol A; Conigrave K; Haber P. Problem drinking: Management in general practice. Australian Family Physician 40(8): 576-+, 2011. (25 refs.)

Background: Management of problem drinking presents the general practitioner with similar challenges and rewards to those associated with the management of other chronic conditions. Objective: This article presents a framework for managing alcohol problems in general practice based on national guidelines for the treatment of alcohol problems. Discussion: General practitioners are well placed to undertake the management of drinking problems following an assessment of the amount of alcohol taken and the risks this poses for the individual and the people around them. This assessment starts the process of engagement and reflection on drinking habits and will inform the appropriate management approach. Brief interventions can result in reduction in drinking in nondependent drinkers. For dependent drinkers, treatment steps include assessing need for withdrawal management and developing a comprehensive management plan, which includes consideration of relapse prevention pharmacotherapy and psychosocial interventions. The patient's right to choose what they drink must be respected, and those who continue to drink in a problematic way can still be assisted, with compassion, within a harm reduction framework.

Demirkol A; Haber P; Conigrave K. Problem drinking: Detection and assessment in general practice. Australian Family Physician 40(8): 570-574, 2011. (27 refs.)

Background: Alcohol has long been an integral part of the social life of many Australians However, alcohol is associated with significant harm to drinkers, and also to nondrinkers. Objective: This article explores the role of the general practitioner in the detection and assessment of problem drinking. Discussion: Excessive alcohol use is a major public health problem and the majority of people who drink excessively go undetected. General practitioners are in a good position to detect excessive alcohol consumption; earlier intervention can help improve outcomes. AUDIT-C is an effective screening tool for the detection of problem drinking. National Health and Medical Research Council guidelines suggest that no more than two standard drinks on each occasion will keep lifetime risk of death from alcohol related disease or injury at a low level. Once an alcohol problem is detected it is important to assess for alcohol dependence, other substance use, motivation to change, psychiatric comorbidities and examination and investigation findings that may be associated with excessive alcohol use. A comprehensive assessment of the impact and risk of harm of the patient's drinking to themselves and others is vital, and may require several consultations.

Dhanani R; Jafferani A; Bhulani N; Azam SI; Khuwaja AK. Predictors of oral tobacco use among young adult patients visiting family medicine clinics in Karachi, Pakistan. Asian Pacific Journal of Cancer Prevention 12(1): 43-47, 2011. (20 refs.)

Prevalence of cancers associated with the use of oral tobacco (OT) is rising very rapidly and prevention of use is the best option to tackle this scenario. This cross-sectional study estimated the proportion of OT use and predictors associated with its initiation and determined the knowledge, attitude and practices of OT users. A total of 231 young adult patients (15-30 years age) were interviewed by medical students in family practice clinics in Karachi, Pakistan. OT use was considered as usage of any of the following: betel quid (paan) with tobacco, betel nuts with tobacco (gutkha), and snuff (naswar). Overall, 49.8% (95% CI=43.3-56.2) subjects had used OT at least in one form. Multivariable analysis demonstrated independent association of OT users with secondary education level (adjusted OR=3.6; 95% CI=1.6-8.1) and use of OT by a family member (OR=2.3; 95% CI=1.3-4.0). Among OT users, 37.4% started after being inspired by friends/peer pressure, 60% using for more than 5 years, 53.2 % users reported getting physical/mental comfort from the use of OT while 31.6% tried to quit this habit but failed. We suggest socially and culturally acceptable educational and behavioral interventions for control of OT usage and hence to prevent its associated cancers.

Doolittle B; Becker W. A case series of buprenorphine/naloxone treatment in a primary care practice. Substance Abuse 32(4): 262-265, 2011. (11 refs.)

Physicians' adoption of buprenorphine/naloxone treatment is hindered by concerns over feasibility, cost, and lack of comfort treating patients with addiction. We examined the use of buprenorphine/naloxone in a community practice by two generalist physicians without addiction training, employing a retrospective chart review. From 2006-2010, 228 patients with opiate abuse/dependence were treated with buprenorphine/naloxone using a home-induction protocol. Multiple co-morbidities including diabetes (23% of patients), hypertension (36%), Hepatitis C (43%), and depression (74%) were concurrently managed. In this diverse sample, 1/228 experienced precipitated withdrawal during induction. Of the convenience subsample analyzed (n = 28), 82% (+/-10%) had negative urine drug tests for opioids; 92% (+/-11%) were negative for cocaine; 88% (+/-12%) were positive for buprenorphine. This case series demonstrated feasibility and safety of a low-cost buprenorphine/naloxone home induction protocol employed by generalists. Concurrent treatment of multiple comorbidities conforms with the patient-centered medical home ideal. Randomized trials of this promising approach are needed.

Ducharme S; Fraser R; Gill K. Update on the clinical use of buprenorphine in opioid-related disorders. (review). Canadian Family Physician 58(1): 37, 2012. (84 refs.)

Objective To review the current evidence on buprenorphine-naloxone for the treatment of opioid-related disorders, with a focus on primary care settings. Quality of evidence MEDLINE and the Cochrane Database of Systemematic Reviews were searched. Evidence is mainly level I. Main message Buprenorphine is a partial kappa-opioid agonist and.-opioid antagonist with a long half-life and less abuse potential than methadone. For detoxification, buprenorphine is at least equivalent to methadone and is superior to clonidine. For maintenance treatment, buprenorphine is clearly superior to placebo. Methadone has a slight advantage in terms of retention in treatment, but a stepped approach with initial use of buprenorphine-naloxone is as efficacious. Use of buprenorphine in the primary care setting is feasible, safe, and effective. Authorization to prescribe buprenorphine can be obtained after completing online training. Conclusion Buprenorphine is a safe and effective agent for detoxification from opioids. It can be used as a first-line agent in maintenance programs, owing to its lower abuse potential relative to other opioids. Its effectiveness in primary care settings makes it a useful therapeutic tool for family physicians.

Duffy SA; Kilbourne AM; Austin KL; Dalack GW; Woltmann EM; Waxmonsky J et al. Risk of smoking and receipt of cessation services among Veterans with mental disorders. Psychiatric Services 63(4): 325-332, 2012. (60 refs.)

Objective: The purpose of this study was to determine rates of smoking and receipt of provider recommendations to quit smoking among patients with mental disorders treated in U.S. Department of Veterans Affairs (VA) treatment settings. Methods: The authors conducted a secondary analysis of the yearly, cross-sectional 2007 Veterans Health Administration Outpatient Survey of Healthcare Experiences of Patients (N=224,193). Logistic regression was used to determine the independent association of mental health diagnosis and the dependent variables of smoking and receipt of provider recommendations to quit smoking. Results: Patients with mental disorders had greater odds of smoking, compared with those without mental disorders (p<.05). Those with various mental disorders reported similar rates of receiving services (more than 60% to 80% reported receiving selected services), compared with those without these disorders, except that those with schizophrenia had more than 30% lower odds of receiving advice to quit smoking from their physicians (p<.05). Moreover, those who had co-occurring posttraumatic stress disorder or substance use disorders had significantly greater odds of reporting that they received advice to quit, recommendations for medications, and physician discussions of quitting methods, compared with those without these disorders (p<.05). Older patients, male patients, members of ethnic minority groups, those who were unmarried, those who were disabled or unemployed, and those living in rural areas had lower odds of receiving selected services (p<.05). Conclusions: The majority of patients with mental disorders served by the VA reported receiving cessation services, yet their smoking rates remained high, and selected groups were at risk for receiving fewer cessation services, suggesting the continued need to disseminate cessation services.

Duggan AE; Duggan JM. Alcoholic liver disease: Assessment and management. Australian Family Physician 40(8): 590-593, 2011. (12 refs.)

Background: Alcohol is a major cause of liver disease in Australia and the incidence of end stage liver disease among young adult Australians is rising. Objective: This article explores the types of alcoholic liver disease, their pathogenesis and detection, and the investigation and management of these conditions. Discussion: Alcoholic liver disease is often silent until complications develop; therefore clinicians need a high index of suspicion to detect individuals with heavy alcohol consumption and evolving liver disease. At a population level, strategies to reduce per capita alcohol consumption can be expected to reduce mortality from alcohol related disease. At an individual level, early diagnosis, abstinence and effective treatment of complications are pivotal to reducing mortality. The cornerstone of management of chronic alcoholic liver disease is abstinence from alcohol and good nutrition. Other important aspects of management include care when prescribing medications, immunisations and early referral for complications.

Fagbemi KS. Q: What is the best questionnaire to screen for alcohol use disorder in an office practice? (editorial). Cleveland Clinic Journal of Medicine 78(10): 649-651, 2011. (14 refs.)

Feigelman S; Dubowitz H; Lane W; Grube L; Kim J. Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment. Academic Pediatrics 11(6): 474-480, 2011. (33 refs.)

OBJECTIVE: The objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child's doctor compared to families receiving standard care from control residents. METHODS: Pediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents' baseline, 6-month, and 18-month post-training surveys, 2) medical record review, and 3) parents' satisfaction regarding doctor-parent interaction. RESULTS: Ninety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor. CONCLUSIONS: The SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.

Feinstein EC; Richter L; Foster SE. Addressing the critical health problem of adolescent substance use through health care, research, and public policy. (editorial). Journal of Adolescent Health 50(5): 431-436, 2012. (99 refs.)

The use of addictive substances-tobacco, alcohol, and other drugs-during adolescence interferes with brain development and increases the risk of serious health and mental health conditions, including addiction. Yet, adolescents live in a culture in which family, social, community, and media influences regularly bombard them with pro-substance use messages, creating an environment in which substance use is considered an expected behavior, rather than a considerable health risk. To prevent the significant harm that falls to teens and young adults because of substance use, The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia) undertook a study to explore how adolescent brain development relates to the risk of substance use and addiction; the cultural influences that create an environment in which substance use is considered normative behavior; individual factors that make some teens more disposed to substance use and addiction; and evidence-based prevention and treatment strategies for addressing this problem. The recently published report "Adolescent Substance Use: America's #1 Public Health Problem" concludes that risky substance use is a major public health problem that can be ameliorated through evidence-based public health measures, including education about the disease and its risk factors, screenings, and clinical interventions, and that addiction can be treated and managed effectively within routine health care practice and specialty care.

Feldman MD; Berkowitz SA. Role of behavioral medicine in primary care. (review). Current Opinion In Psychiatry 25(2): 121, 2012. (85 refs.)

Purpose of review: Behavioral medicine is a vast field with an ever-increasing knowledge base. We review important findings over the last 18 months. Recent findings: We organized advances in behavioral medicine into four main topic areas: the doctor and patient, health-related behavior, integration of behavioral medicine in primary care, and teaching and assessing behavioral medicine competencies in primary care. Section I reviews research on difficult encounters, delivering bad and sad news, and physician well being. Section II examines improvements in the treatment of obesity and tobacco abuse, as well as interventions which boost adherence. Section III discusses advancements in care management and collaborative care in the USA and resource-constrained settings. Finally, section IV deals with teaching and assessing communication skills, behavior change, and professionalism. Summary: Physician skills such as communication, professionalism, behavior change, and self-care are not innate abilities, but teachable and learnable skills. Collaborative care and the integration of behavioral medicine with care for other conditions can benefit patients, and can be done effectively with case management and telemonitoring strategies. Future behavioral medicine research should include evaluation of implementation strategies so that we may incorporate principles of behavioral medicine more widely into clinical practice.

Fine PG; Finnegan T; Portenoy RK. Protect your patients, protect your practice. Practical risk assessment in the structuring of opioid therapy in chronic pain. Journal of Family Practice 59(9, supplement 2): S1-S16, 2010. (42 refs.)

Primary care clinicians play a crucial role in the assessment and management of chronic pain. As many as one-third of primary care patients report having chronic pain. Unfortunately, the increased availability and prescription of opioid analgesics in recent years have been accompanied by a parallel increase in prescription opioid abuse and misuse and related morbidity and mortality.3-5 Prescription drug abuse is an increasingly serious public health problem, and this reality has reinforced the view that primary care clinicians must possess skills in risk assessment and management, as well as the ability to optimize the potentially favorable effects of opioid drugs on pain and function. To help address the problem of prescription drug abuse while still allowing for the prescription of opioids for pain relief, policy makers involved in the development of health care regulations have started adopting the principle of balance. The key principles for assessment and management of the risks associated with misuse, abuse, addiction, and diversion are described, as are indications for referral to pain/addiction specialists.

Gilchrist G; Moskalewicz J; Slezakova S; Okruhlica L; Torrens M; Vajd R et al. Staff regard towards working with substance users: A European multi-centre study. Addiction 106(6): 1114- 1125, 2011. (57 refs.)

Aims: To compare regard for working with different patient groups (including substance users) among different professional groups in different health-care settings in eight European countries. Design: A multi-centre, cross-sectional comparative study. Setting: Primary care, general psychiatry and specialist addiciton services in Bulgaria, Greece, Italy, Poland, Scotland, Slovakia, Slovenia and Spain. Participants: A multi-disciplinary convenience sample of 866 professionals (physicians, psychiatrists, psychologists, nurses and social workers) from 253 services. Measurements: The Medical Condition Regard Scale measured regard for working with different patient groups. Multi-factor between-subjects analysis of variance determined the factors associated with regard for each condition by country and all countries. Findings: Regard for working with alcohol (mean score alcohol: 45.35, 95% CI 44.76, 45.95) and drug users (mean score drugs: 43.67, 95% CI 42.98, 44.36) was consistently lower than for other patient groups (mean score diabetes: 50.19, 95% CI 49.71, 50.66; mean score depression: 51.34, 95% CI 50.89, 51.79) across all countries participating in the study, particularly among staff from primary care compared to general psychiatry or specialist addiction services (P < 0.001). After controlling for sex of staff, profession and duration of time working in profession, treatment entry point and country remained the only statistically significant variables associated with regard for working with alcohol and drug users. Conclusions: Health professionals appear to ascribe lower status to working with substance users than helping other patient groups, particularly in primary care; the effect is larger in some countries than others.

Girgis S; Adily A; Velasco MJ; Zwar NA; Jalaludin BB; Ward JE. Feasibility, acceptability and impact of a telephone support service initiated in primary medical care to help Arabic smokers quit. Australian Journal of Primary Health 17(3): 274-281, 2011. (37 refs.)

Evidence-based tobacco control in ethnic minorities is compromised by the near absence of rigorous testing of interventions in either prevention or cessation. This randomised controlled trial was designed to evaluate the feasibility, acceptability and impact of a culturally specific cessation intervention delivered in the context of primary medical care in the most culturally diverse region of New South Wales. Adult Arabic smokers were recruited from practices of 29 general practitioners (GPs) in south-west Sydney and randomly allocated to usual care (n = 194) or referred to six sessions of smoking cessation telephone support delivered by bilingual psychologists (n = 213). Although 62.2% of participants indicated that telephone support would benefit Arabic smokers, there were no significant differences at 6 or 12 months between intervention and control groups in point prevalence abstinence rates (11.7% vs 12.9%, P = 0.83; 8.4% vs 11.3%, P = 0.68, respectively) or the mean shift in stage-of-change towards intention to quit. As participants and GPs found telephone support acceptable, we also discuss redesign and the unfulfilled obligation to expand the evidence base in tobacco control from which the ethnic majority already benefits.

Glass JE; Bucholz KK. Concordance between self-reports and archival records of physician visits: A case-control study comparing individuals with and without alcohol use disorders in the community. Drug and Alcohol Dependence 116(1-3): 57-63, 2011. (24 refs.)

Objective: The accuracy of self-reported healthcare use among individuals with alcohol use disorders (AUD) has been questioned. The present study attempts to compare the accuracy of self-reported physician visits for individuals who differ with respect to their history of AUDs. Methods: Our data source was a 14-year follow-up of individuals interviewed at the St. Louis site of the 1981-1983 Epidemiologic Catchment Area Study (ECA). We used a case-control design (n = 237) to compare the accuracy of self-reports among ECA participants with stably diagnosed AUDs (cases; n = 75) to two comparison groups: those with problem/very heavy drinking (n = 81) and those unaffected by alcohol (n = 81). Intraclass correlation coefficients (ICC) described the concordance between self-reports and archival records of physician visits in the prior six months. We used multinomial logistic regression to identify characteristics associated with under-reporting and over-reporting, and zero-truncated Poisson regression to identify characteristics associated with discordance severity. Results: Self-reports of cases had substantial concordance with physician records (ICC = 0.74, Cl = 0.61-0.83). As compared to cases, those with problem/very heavy drinking had a significantly higher ICC, and those who were unaffected by alcohol had a significantly lower ICC. However, differences in concordance disappeared when using regression models that adjusted for factors known to affect the accuracy of self-reported healthcare use. Utilization frequency was a strong predictor of inaccurate reporting. Conclusions: These findings suggest AUD status may not independently affect the accuracy of self-reports. Counts of physician visits for those with AUD may be considered accurate when utilization frequency is low.

Goodie JL; Williams PM; Kurzweil D; Marcellas KB. Can blended classroom and distributed learning approaches be used to teach medical students how to initiate behavior change counseling during a clinical clerkship? Journal of Clinical Psychology In Medical Settings 18(4): 353-360, 2011. (40 refs.)

Medical school curricula often provide insufficient time and instruction for health behavior change counseling. We examined the feasibility of blending classroom and distributed learning experiences to teach medical students how to initiate health behavior change counseling and analyzed the impact of this approach on their attitudes, knowledge, and skills. Usage patterns and pre- to post-class attitude and knowledge changes were assessed with self-report questions among 153 third year family medicine clerkship students. Most students viewed at least 90% of the online written content and took an average of 41 min (SD = 24 min 35 s) to view all of the content. Students' confidence in their ability to help patients change unhealthy behaviors significantly improved (p < .01). The blended learning curriculum facilitated learning of behavior change skills, encouraged interaction with course materials, and improved medical students' self confidence for using health behavior change skills.

Gunderson EW; Levin FR; Rombone MM; Vosburg SK; Kleber HD. Improving temporal efficiency of outpatient buprenorphine Induction. American Journal on Addictions 20(5): 397-404, 2011. (32 refs.)

Buprenorphine induction poses a barrier for physician adoption of office-based opioid dependence treatment. We conducted a retrospective chart review of the first 41 patients inducted at a newly established outpatient treatment program to examine the induction process and determine strategies associated with greater induction efficiency. Timed withdrawal scales, medication log, and notes enabled reconstruction of the initial day of buprenorphine treatment. To assess change with experience, consecutive patients were divided into three chronological groups for analyses (Phases 1-3). The time required for induction was substantial in Phase 1 (mean 5.5 hours), but temporal efficiency improved to a mean 1.5 hours spent at the program by Phase 3 (p <.001). Phase 2-3 patients arrived to the program after significantly longer opioid abstinence and were in greater withdrawal, with mean Clinical Opioid Withdrawal Scale scores of 6, 10, and 10 for Phases 1-3, respectively (p <.01). Patients in the later phases had less time delay to medication initiation, 5 minutes in Phase 3 compared to 133 minutes in Phase 1 (p <.001). The mean 7-mg buprenorphine dose administered in the office did not differ between groups, but occurred over a smaller time interval for later phases indicating more rapid titration. Patients in the later phases had more rapid withdrawal relief after buprenorphine initiation and were more likely to have used preinduction ancillary withdrawal medication. The study sheds light on the induction barrier and provides practical procedural information to inform clinical guidelines and hopefully mitigate procedural aspects of the induction barrier.

Hansen EC; Nelson MR. How cardiac patients describe the role of their doctors in smoking cessation: A qualitative study. Australian Journal of Primary Health 17(3): 268-273, 2011. (37 refs.)

This article reports a qualitative study investigating patients' experiences of ongoing smoking or smoking cessation after hospitalisation for an acute coronary syndrome (myocardial infarction or unstable angina) and describes how study participants spoke about the role of their doctors in smoking cessation. We invited individuals who had been admitted to an Australian public hospital in 2005 with a discharge diagnosis of an acute cardiac syndrome and who were smokers at the time of their hospitalisation to participate. Participants underwent a semi-structured interview and ongoing smokers also completed a 'stages of change' questionnaire. In total, 35 participants were interviewed, including 14 who were no longer smoking at least 12 months after their admission and 21 who were. Findings gave insight into the ways that cardiac patients perceive smoking cessation advice from their doctors, the perceived stigma of smoking and how lay understandings about smoking and smoking cessation emphasise the role of choice and individual responsibility. Our findings also indicate considerable scope for GPs and other doctors to offer better smoking cessation support to patients with established cardiovascular disease, particularly after a period of hospitalisation when the majority are highly motivated to stop smoking.

Harrison PA; Godecker A; Sidebottom AC. Psychosocial risk screening during pregnancy: Additional risks identified during a second interview. Journal of Health Care for the Poor and Underserved 22(4): 1344-1357, 2011. (37 refs.)

The Prenatal Risk Overview (PRO) screens for 13 psychosocial risk factors associated with poor birth outcomes. This study assessed the extent to which risk factors unreported during an intake interview were identified during a subsequent interview. A total of 708 pregnant women were screened and re-screened at three urban community health care centers between July 2007 and April 2010. Study participants were predominantly young (mean age 23.5 years), unmarried (75.1%) women of color (92.5%); 38.4% were foreign-born. The proportional increase in participants identified as being at risk for individual domains at the second interview ranged from 5.6% to 49.0% for the combined Moderate/High Risk classification and from 5.6% to 73.0% for the High Risk only classification. For women whose health and well-being are challenged by poverty, violence, social isolation, and other stressors, both initial screening and repeat screening offer opportunities to alleviate identified risks.

Heather N; Paton J; Ashton H. Predictors of response to brief intervention in general practice against long-term benzodiazepine use. Addiction Research & Theory 19(6): 519-527, 2011. (41 refs.)

Aims: To predict the response of mostly elderly patients to brief intervention against long-term benzodiazepine (BZD) use delivered in general medical practice from variables measured at baseline in a randomised controlled trial. Method: Logistic regression was used to identify predictors of a complete cessation of BZD intake or a 'clinically significant reduction' by a half or more from baseline to 6 months follow-up among 183 patients who received a brief intervention. Candidate predictor variables were: (i) stage of change (ii) level of BZD dependence (iii) whether BZDs were prescribed by the patient's usual general practitioner (GP) or by another medical practitioner; (iv) baseline BZD dosage; (v) type of BZD and (vi) gender. Results: Both cessation and reduction were predicted by who prescribed BZDs, with patients whose medication was prescribed by their usual GP more likely to show a positive response to brief intervention than those whose medication was prescribed by another medical practitioner. Stage of change was a significant predictor of a reduction in BZD use, with patients in the Contemplation stage nearly three times more likely, and those in the Action stage over eight times more likely, to achieve a clinically significant reduction than those in the Precontemplation stage. Conclusions: Patients receiving prescriptions from their usual GP are more likely to cease or reduce BZD intake than those receiving prescriptions from another medical practitioner. In managing patients with long-term use of BZDs, general medical practitioners should consider recording the patient's stage of change and tailoring their intervention on that basis.

Henderson S; DeGroff A; Richards TB; Kish-Doto J; Soloe C; Heminger C et al. A qualitative analysis of lung cancer screening practices by primary care physicians. Journal of Community Health 36(6): 949-956, 2011. (24 refs.)

Lung cancer is the leading cause of cancer death in the United States, but no scientific organization currently recommends screening because of limited evidence for its effectiveness. Despite this, physicians often order screening tests such as chest X-rays and computerized tomography scans for their patients. Limited information is available about how physicians decide when to order these tests. To identify factors that affect whether physicians' screen patients for lung cancer, we conducted five 75-min telephone-based focus groups with 28 US primary care physicians and used inductive qualitative research methods to analyze their responses. We identified seven factors that influenced these physicians' decisions about screening patients for lung cancer: (1) their perception of a screening test's effectiveness, (2) their attitude toward recommended screening guidelines, (3) their practice experience, (4) their perception of a patient's risk for lung cancer, (5) reimbursement and payment for screening, (6) their concern about litigation, and (7) whether a patient requested screening. Because these factors may have conflicting effects on physicians' decisions to order screening tests, physicians may struggle in determining when screening for lung cancer is appropriate. We recommend (1) more clinician education, beginning in medical school, about the existing evidence related to lung cancer screening, with emphasis on the benefit of and training in tobacco use prevention and cessation, (2) more patient education about the benefits and limitations of screening, (3) further studies about the effect of patients' requests to be screened on physicians' decisions to order screening tests, and (4) larger, quantitative studies to follow up on our formative data.

Hingson RW; Heeren T; Edwards EM; Saitz R. Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol. Journal of General Internal Medicine 27(2): 179, 2012. (35 refs.)

Excessive alcohol consumption is most widespread among young adults. Practice guidelines recommend screening and physician advice, which could help address this common cause of injury and premature death. To assess the proportion of persons ages 18-39 who, in the past year, saw a physician and were asked about their drinking and advised what drinking levels pose health risk, and whether this differed by age or whether respondents exceeded low-risk drinking guidelines [daily (> 4 drinks for men/> 3 for women) or weekly (> 14 for men/> 7 for women)]. Survey of young adults selected from a national internet panel established using random digit dial telephone techniques. Adults age 18-39 who ever drank alcohol, n = 3,409 from the internet panel and n = 612 non-panel telephone respondents. Respondents were asked whether they saw a doctor in the past year; those who did see a doctor were asked whether a doctor asked about their drinking, advised about safe drinking levels, or counseled to reduce drinking. Of respondents, 67% saw a physician in the past year, but only 14% of those exceeding guidelines were asked and advised about risky drinking patterns. Persons 18-25 were the most likely to exceed guidelines (68% vs. 56%, p < 0.001) but were least often asked about drinking (34% vs. 54%, p < 0.001). Despite practice guidelines, few young adults are asked and advised by physicians about excessive alcohol consumption. Physicians should routinely ask all adults about their drinking and offer advice about levels that pose health risk, particularly to young adults.

Holliday SM. Managing the continuum between pain and dependency in general practice. (editorial). Drug and Alcohol Review 30(3): 324- 326, 2011. (27 refs.)

Holliday SM; Magin PJ; Dunbabin JS; Ewald BD; Henry JM; Goode SM et al. Waiting room ambience and provision of opioid substitution therapy in general practice. Medical Journal of Australia 196(6): 391-394, 2012. (17 refs.)

Objective: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices - a perceived barrier that prevents general practitioners from prescribing OST. Design, setting and participants: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August - December 2009. Main outcome measures: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction. Results: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10. Conclusions: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs' concerns that prescribing OST in their practices would have a negative impact on other patients' waiting room experiences or on retention of patients seem to be unfounded.

Hollowell J; Oakley L; Kurinczuk JJ; Brocklehurst P; Gray R. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: A systematic review. (review). BMC Pregnancy and Childbirth 11: 13, 2011. (83 refs.)

Background: Infant mortality has shown a steady decline in recent years but a marked socioeconomic gradient persists. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but the effectiveness of specific antenatal care programmes as a means of reducing infant mortality in socioeconomically disadvantaged and vulnerable groups of women has not been rigorously evaluated. Methods: We conducted a systematic review, focusing on evidence from high income countries, to evaluate the effectiveness of alternative models of organising or delivering antenatal care to disadvantaged and vulnerable groups of women vs. standard antenatal care. We searched Medline, Embase, Cinahl, PsychINFO, HMIC, CENTRAL, DARE, MIDIRS and a number of online resources to identify relevant randomised and observational studies. We assessed effects on infant mortality and its major medical causes (preterm birth, congenital anomalies and sudden infant death syndrome (SIDS)). Results: We identified 36 distinct eligible studies covering a wide range of interventions, including group antenatal care, clinic-based augmented care, teenage clinics, prenatal substance abuse programmes, home visiting programmes, maternal care coordination and nutritional programmes. Fifteen studies had adequate internal validity: of these, only one was considered to demonstrate a beneficial effect on an outcome of interest. Six interventions were considered 'promising'. Conclusions: There was insufficient evidence of adequate quality to recommend routine implementation of any of the programmes as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

Islam MM; Topp L; Day CA; Dawson A; Conigrave KM. Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group. (editorial). International Journal of Drug Policy 23(2): 109-110, 2012. (13 refs.)

Islam MM; Topp L; Day CA; Dawson A; Conigrave KM. The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. (review). International Journal of Drug Policy 23(2): 94-102, 2012. (64 refs.)

Background: Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IOU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population. Methods: Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents. Results: Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals. Conclusions: Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented.

Johnson K; Isham A; Shah DV; Gustafson DH. Potential roles for new communication technologies in treatment of addiction. Current Psychiatry Reports 13(5): 390-397, 2011. (81 refs.)

Information and communication technologies offer clinicians the opportunity to work with patients to manage chronic conditions, including addiction. The early research on the efficacy of electronic treatment and support tools is promising. Sensors have recently received increased attention as key components of electronic treatment and recovery management systems. Although results of the research are very promising, concerns at the clinical and policy level must be addressed before widespread adoption of these technologies can become practical. First, clinicians must adapt their practices to incorporate a continuing flow of patient information. Second, payment and regulatory systems must make adjustments far beyond what telemedicine and electronic medical records have required. This paper examines potential roles of information and communication technologies as well as process and regulatory challenges.

Jones KA; Nielsen S; Bruno R; Frei M; Lubman DI. Benzodiazepines: Their role in aggression and why GPS should prescribe with caution. Australian Family Physician 40(11): 862-865, 2011. (27 refs.)

Background: Benzodiazepines are widely prescribed in Australia, despite concerns about their potential for abuse and dependence. Paradoxical reactions, disinhibition and amnesia are all associated with benzodiazepine use, misuse and intoxication. While violent and aggressive behaviour may be a consequence of such disinhibition, there is limited information available regarding the links between benzodiazepine use and violence. Objective This article aims to examine the existing evidence on the relationship between benzodiazepines, violence and aggression. Discussion While current evidence suggests that benzodiazepines rarely induce violence, it is important to note that the available literature is limited in its scope and that benzodiazepine related violence is often severe and of potential concern to frontline workers. Mediating risk factors for benzodiazepine related violence include concurrent alcohol use, benzodiazepine dose, a history of aggression and underlying impulsivity. Comprehensive assessment and alternate nonpharmacological treatment options should be considered before prescribing benzodiazepines within primary care.

Jones SC; Telenta J; Cert G; Shorten A; Johnson K. Midwives and pregnant women talk about alcohol: What advice do we give and what do they receive? Midwifery 27(4): 489-496, 2011. (39 refs.)

Background: the Australian National Health and Medical Research Council (NHMRC) recently revised its guidelines for alcohol consumption during pregnancy and breast feeding, moving from a recommendation of minimising intake to one of abstinence. Women are potentially exposed to a variety of messages about alcohol and pregnancy, including from the media and social contacts, and are likely to see midwives as the source of expert advice in understanding these contradictory messages. Objective: to explore the advice that midwives believe they give to pregnant women about alcohol consumption, and the advice that pregnant women believe they receive; the knowledge and attitudes of both groups regarding alcohol consumption and the consistency with the NHMRC guidelines; and the receptivity and comfort of both groups in discussing alcohol consumption in the context of antenatal appointments. Design: individual semi-structured interviews with midwives and pregnant women. Setting: face-to-face interviews with midwives and telephone interviews with pregnant women were conducted in two regional areas of New South Wales in 2008-2009. Participants: 12 midwives and 12 pregnant women. Findings: midwives and pregnant women consistently agreed that conversations about alcohol are generally limited to brief screening questions at the first visit, and the risks are not discussed or explained (except for high-risk women). Key conclusions: both groups expressed comfort with the idea of discussing alcohol consumption, but lacked knowledge of the risk and recommendation, and it appears that this opportunity to provide women with information is under-utilised. Implications for practice: there is a need to provide midwives with accurate information about the risks of alcohol consumption during pregnancy and effective communication tools to encourage them to discuss the risks and recommendations with their patients.

Jones SC; Telenta J. What influences Australian women to not drink alcohol during pregnancy? Australian Journal of Primary Health 18(1): 68-73, 2012. (28 refs.)

There is a strong social norm against consuming alcohol during pregnancy. However, many women do not realise they are pregnant until the sixth week and are not provided with information about the risks of consuming alcohol until they visit a health professional in the second trimester. We conducted semi-structured interviews with 12 midwives and 12 pregnant women from two regions in NSW in 2008-09 to explore attitudes towards alcohol consumption during pregnancy, and the factors that may encourage or inhibit women from following the recommendation to abstain from drinking while pregnant. Both groups noted the social issues around pregnant women consuming alcohol due to perceived social norms and the challenges in not revealing early pregnancy status at social events.

Kahan M; Mailis-Gagnon A; Wilson L; Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 1: general population. (review). Canadian Family Physician 57(11): 1257-1266, 2011. (71 refs.)

Objective To provide family physicians with a practical clinical summary of the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, developed by the National Opioid Use Guideline Group. Quality of evidence Researchers for the guideline conducted a systematic review of the literature on the effectiveness and safety of opioids for chronic noncancer pain, and drafted a series of recommendations. A panel of 49 clinicians from across Canada reviewed the draft and achieved consensus on 24 recommendations. Main message Screening for addiction risk is recommended before prescribing opioids. Weak opioids (codeine and tramadol) are recommended for mild to moderate pain that has not responded to first-line treatments. Oxycodone, hydromorphone, and morphine can be tried in patients who have not responded to weaker opioids. A low initial dose and slow upward titration is recommended, with patient education and close monitoring. Physicians should watch for the development of complications such as sleep apnea. The optimal dose is one which improves function or decreases pain ratings by at least 30%. For by far most patients, the optimal dose will be well below a 200-mg morphine equivalent dose per day. Tapering is recommended for patients who have not responded to an adequate opioid trial. Conclusion: Opioids play an important role in the management of chronic noncancer pain, but careful prescribing is needed to limit potential harms. The new Canadian guideline provides much-needed guidance to help physicians achieve a balance between optimal pain control and safety.

Kahan M; Wilson L; Mailis-Gagnon A; Srivastava A. Canadian guideline for safe and effective use of opioids for chronic noncancer pain. Clinical summary for family physicians. Part 2: special populations. (review). Canadian Family Physician 57(11): 1269-1276, 2011. (66 refs.)

Objective: To provide family physicians with a practical clinical summary of opioid prescribing for specific populations based on recommendations from the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Quality of evidence: Researchers for the guideline conducted a systematic review of the literature, focusing on reviews of the effectiveness and safety of opioids in specific populations. Main message: Family physicians can minimize the risks of overdose, sedation, misuse, and addiction through the use of strategies tailored to the age and health status of patients. For patients at high risk of addiction, opioids should be reserved for well-defined nociceptive or neuropathic pain conditions that have not responded to first-line treatments. Opioids should be titrated slowly, with frequent dispensing and close monitoring for signs of misuse. Suspected opioid addiction is managed with structured opioid therapy, methadone or buprenorphine treatment, or abstinence-based treatment. Patients with mood and anxiety disorders tend to have a blunted analgesic response to opioids, are at higher risk of misuse, and are often taking sedating drugs that interact adversely with opioids. Precautions similar to those for other high-risk patients should be employed. The opioid should be tapered if the patient's pain remains severe despite an adequate trial of opioid therapy. In the elderly, sedation, falls, and overdose can be minimized through lower initial doses, slower titration, benzodiazepine tapering, and careful patient education. For pregnant women taking daily opioid therapy, the opioids should be slowly tapered and discontinued. If this is not possible, they should be tapered to the lowest effective dose. Opioid-dependent pregnant women should receive methadone treatment. Adolescents are at high risk of opioid overdose, misuse, and addiction. Patients with adolescents living at home should store their opioid medication safely. Adolescents rarely require long-term opioid therapy. Conclusion: Family physicians must take into consideration the patient's age, psychiatric status, level of risk of addiction, and other factors when prescribing opioids for chronic pain.

Katz A; Lambert-Lanning A; Miller A; Kaminsky B; Enns J. Delivery of preventive care: The National Canadian Family Physician Cancer and Chronic Disease Prevention Survey. Canadian Family Physician 58(1): E62, 2012. (43 refs.)

Objective: To determine family physicians' practice of, knowledge about, and attitudes toward delivering preventive care during periodic health examinations (PHEs). Design A stratified sample of 5013 members of the College of Family Physicians of Canada were randomly selected to receive a questionnaire by mail. Descriptive analysis was performed on a national data set of 1010 respondents. Setting: Canada. Participants A sample of family physicians from each Canadian province. Main outcome measures Physicians were asked questions about whether they addressed aspects of preventive care, such as tobacco smoking, nutrition, physical activity, alcohol intake, and sun exposure with patients during PHEs. The questions were designed to gauge attitudes and identify barriers to the provision of preventive care. Results: Most respondents (87% to 89%) indicated that they were comfortable counseling their patients about issues such as nutrition, physical activity, and alcohol consumption; however, many of these respondents did not refer their patients to specialists or provide them with additional resources to educate patients about the health risks of their conditions. While tobacco smoking risks and cessation were addressed by most family physicians (79%) during PHEs, other topics, such as sun exposure, were often overlooked. Conclusion The results of this survey indicate that while many family physicians follow the evidence-based guidelines for preventive care, current levels of preventive care in the primary care setting are below national standards. It is critical that Canadians receive optimal preventive care to improve the outlook of the chronic disease burden on the health care system.

Kennedy RD; Behm I; Craig L; Thompson ME; Fong GT; Guignard R; Beck F. Smoking cessation interventions from health care providers before and after the national smoke-free law in France. European Journal of Public Health 22(Supplement 1): 23, 2012. (24 refs.)

Background: Smoking cessation advice from health care providers (HCP) is well-known to be associated with increased quitting. This study sought to understand the extent to which smokers in France who visited a HCP around the time of the implementation of the national ban on smoking received encouragement to quit from a HCP and what kinds of intervention were provided. HCP may have a unique opportunity during the implementation phase of smoke-free laws to address their patients' smoking behaviours to increase the likelihood of success at a time when smokers' readiness and interest in quitting may be higher. Methods: Telephone interviews were conducted among adult smokers (n = 1067) before and after the two-phase (2007 and 2008) national ban on indoor smoking as part of the International Tobacco Control (ITC) France Survey. In the survey, smokers were asked whether they had visited a HCP in the past 6 months and, if so, whether they had received cessation encouragement, and/or other interventions to support quitting such as prescriptions for stop-smoking medication. Results: Most smokers (61%) reported visiting a HCP in the 6 months prior to the first phase of the national smoke-free ban, and 58% after the time of the hospitality ban. Of these, most reported they did not receive any assistance from a HCP before (54%) or after (64%) the smoke-free law. Among those who reported an intervention, the most common were only encouragement to quit (58% in Wave 1 and 49% in Wave 2), or receiving both encouragement and a pamphlet (31% in both Wave 1 and 2). The combination of prescriptions for stop-smoking medicine and encouragement to quit increased from 8% in 2007 to 22% in 2008. The smokers who received an intervention were more likely (OR 1.9, 95% CI: 1.2-2.9) to report that they were thinking about quitting. Discussion: This study demonstrates that HCP in France are well positioned to provide smoking cessation encouragement and other interventions to a majority of smokers and thus the importance of taking measures to increase their involvement, particularly when population-level tobacco control policies, such as smoke-free laws, are being implemented.

Kesmodel US; Kesmodel PS; Iversen LL. Lack of consensus between general practitioners and official guidelines on alcohol abstinence during pregnancy. Danish Medical Bulletin 58(10): A4327, 2011. (18 refs.)

INTRODUCTION: Many pregnant women in Denmark have been advised that some alcohol intake is acceptable. In the 1999-2007-period, the Danish National Board of Health advised pregnant women that some alcohol intake was acceptable. From 2007, alcohol abstinence has been recommended. We aimed to describe the attitudes towards and knowledge about alcohol in pregnancy among general practitioners (GPs) in Denmark in 2000 and in 2009. MATERIAL AND METHODS: In 2000, we invited a representative sample of GPs in the catchment area of the Antenatal Care Centre in Aarhus to participate in the study. Participants were interviewed about their attitudes, beliefs, knowledge and information practice in relation to alcohol in pregnancy. Identical questions were sent to all GPs in the area in 2009. RESULTS: In 2000, most GPs (71%) considered that some alcohol intake in pregnancy was acceptable, mostly on a weekly level. There was considerable inter-person variation in the participants' attitudes and recommendations to pregnant women. In 2009, significantly more GPs (51%) considered abstinence to be preferable, and significantly more GPs (53%) gave this advice to pregnant women than in 2000. Their knowledge about the official recommendations on alcohol was good. Older GPs were more likely to recommend abstinence. CONCLUSIONS: The attitudes towards and knowledge about drinking in pregnancy among GPs have changed along with the change in official policy.

Kim TW; Saitz R; Cheng DM; Winter MR; Witas J; Samet JH. Initiation and engagement in chronic disease management care for substance dependence. Drug and Alcohol Dependence 115(1-2): 80-86, 2011. (46 refs.)

Background: Substance dependence treatment is often episodic and not well coordinated with healthcare for common comorbidities. Chronic disease/care management (CDM), longitudinal, patient-centered care delivered by multidisciplinary health professionals, may be well suited to treat substance dependence (SD). Objective: To examine initiation and engagement with CDM care for SD located in a primary medical setting. Methods: We prospectively studied substance dependent participants enrolled in a trial of CDM addiction care. Primary study outcomes, based upon Washington Circle performance measures, were 14-day initiation of CDM care and 30-day engagement with CDM care. Factors associated with these outcomes were determined using multivariable logistic regression models. We also estimated the proportion of participants who eventually attended at least two visits and four visits by the end of the study (Kaplan-Meier method). Results: Of 282 participants, approximately half of the cohort (45%, 95% Confidence Interval [CI] 39-51%) met criteria for 14-day initiation and 23% (95% CI 18-28%) for 30-day engagement with CDM care. Most participants attended two or more (81%, 95% Cl 76-85%) and four or more CDM visits (62%, 95% Cl 56-68%). Major depressive episode (AOR 2.60, 95% CI 1.39, 4.87) was associated with higher odds of 14-day initiation; younger age, female sex, and higher alcohol addiction severity were associated with lower odds of 30-day engagement with CDM care. Conclusion: People with SD appear to be willing to initiate and engage with CDM care in a primary medical care setting. CDM care has the potential to improve the quality of care for people with addictions.

Langley TE; Szatkowski LC; Wythe S; Lewis SA. Can primary care data be used to monitor regional smoking prevalence? An analysis of The Health Improvement Network primary care data. BMC Public Health 11: e-773, 2011

Accurate and timely regional data on smoking trends allow tobacco control interventions to be targeted at the areas most in need and facilitate the evaluation of such interventions. Electronic primary care databases have the potential to provide a valuable source of such data due to their size, continuity and the availability of socio-demographic data. UK electronic primary care data on smoking prevalence from The Health Improvement Network (THIN) have previously been validated at the national level, but may be less representative at the regional level due to reduced sample sizes. We investigated whether this database provides valid regional data and whether it can be used to compare smoking prevalence in different UK regions. Annual estimates of smoking prevalence by government office region (GOR) from THIN were compared with estimates of smoking prevalence from the General Lifestyle Survey (GLF) from 2000 to 2008. For all regions, THIN prevalence data were generally found to be highly comparable with GLF data from 2006 onwards. THIN primary care data could be used to monitor regional smoking prevalence and highlight regional differences in smoking in the UK.

Lee JD; Grossman E; Truncali A; Rotrosen J; Rosenblum A; Magura S et al. Buprenorphine-naloxone maintenance following release from jail. Substance Abuse 33(1, special issue): 40-47, 2012. (20 refs.)

Primary care is understudied as a reentry drug and alcohol treatment setting. This study compared treatment retention and opioid misuse among opioid-dependent adults seeking buprenorphine/naloxone maintenance in an urban primary care clinic following release from jail versus community referrals. Postrelease patients were either (a) induced to buprenorphine in-jail as part of a clinical trial, or (b) seeking buprenorphine induction post release. From 2007 to 2008, N = 142 patients were new to primary care buprenorphine: n = 32 postrelease; n = 110 induced after community referral and without recent incarceration. Jail-released patients were more likely African American or Hispanic and uninsured. Treatment retention rates for postrelease (37%) versus community (30%) referrals were similar at 48 weeks. Rates of opioid positive urines and self-reported opioid misuse were also similar between groups. Postrelease patients in primary care buprenorphine treatment had equal treatment retention and rates of opioid abstinence versus community-referred patients.

Liddy C; Singh J; Hogg W; Dahrouge S; Taljaard M. Comparison of primary care models in the prevention of cardiovascular disease: A cross sectional study. BMC Family Practice 12: 114, 2011. (36 refs.)

Background: Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models. Methods: This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models. Results: The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management. Conclusions: This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.

Liebschutz JM; Alford DP. Safe opioid prescribing: A long way to go. (editorial). Journal of General Internal Medicine 26(9): 951-952, 2011. (22 refs.)

Lipkin M; Lee J. Alcoholism in primary care. (Chapter 13). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter is part of Part II, a section with the title "The Real World." The chapters in this section focus on particular drugs. This chapter deals with alcohol/alcoholism and its presentation and clinical care in primary care.. Other chapters in this section deal with twelve step approaches; nicotine addiction and smoking cessation; clinical approaches in working with cocaine and methadone dependence; methadone maintenance for opiate dependence; and prescription drug abuse.

Lofwall MR; Wunsch MJ; Nuzzo PA; Walsh SL. Efficacy of continuing medical education to reduce the risk of buprenorphine diversion. Journal of Substance Abuse Treatment 41(3): 321-329, 2011. (31 refs.)

As office-based opioid dependence treatment (OBOT) has grown in the United States, postmarketing surveillance data reveal increased reports of buprenorphine misuse and diversion, it is important that doctors understand buprenorphine clinical pharmacology and engage in practices to decrease risk of misuse, diversion, and other adverse events. This study evaluated the efficacy of continuing medical education (CME) in two U.S. regions with surveillance signals of buprenorphine misuse/diversion. Four surveys (before, on-site, and 1 and 3 months post CME) evaluated physician characteristics, practice behaviors, and buprenorphine pharmacology and legislative knowledge. The results show that physicians had limited addictions training. Knowledge and practice behaviors significantly improved after the CME, which should enhance the quality of OBOT and may decrease risk of buprenorphine misuse and diversion from their practices. Mandatory CME targeting OBOT-certified physicians could have a positive impact on patient and public health outcomes.

Ludt S; Petek D; Laux G; van Lieshout J; Campbell SM; Kunzi B et al. Recording of risk-factors and lifestyle counselling in patients at high risk for cardiovascular diseases in European primary care. European Journal of Preventive Cardiology 19(2): 258-266, 2012. (32 refs.)

Background: Detection and registration of high risk for cardiovascular diseases (CVD) by assessing individual's absolute cardiovascular risk is recommended in clinical guidelines. Effective interventions to reduce cardiovascular risk are available, but not optimally implemented. The aim of this study was to assess the quality of cardiovascular risk-factor recording and lifestyle counselling in high-risk patients in European primary care and to identify factors related to these clinical processes. Methods: An international cross-sectional observational study was conducted in stratified samples of primary care practices in nine European countries. Patient records were audited, using a structured data-abstraction tool based on internationally developed quality indicators. To identify factors associated with the recording, additional data were collected in a patient survey. Descriptive and multilevel data analyses were conducted. Results: In 268 general practices across Europe, 3723 records of individuals at high risk for cardiovascular diseases were audited. We found important variations in the quality of documentation of risk factors and lifestyle interventions. Recording of risk factors was best for blood pressure (92.5% of audited records, 95% Cl 0.89-0.96). Lifestyle advice was recorded best for smoking cessation (65.6%, 95% Cl 0.58-0.73) and worst for physical activity (38.8%, 95% CI 0.31-0.47). Of the study population, 50.6% (0.42-0.59) had elevated blood pressure levels, 59.8% (0.51-0.69) had total cholesterol >5 mmol/l, and 30.5% (0.22-0.39) were smokers. Multivariate analyses showed that recording of risk factors and counselling were related to specific patient characteristics more than to country effects. Conclusions: Analysis of different country results can be helpful for developing quality-improvement strategies.

Mahvan T; Namdar R; Voorhees K; Smith PC; Flake D. Which smoking cessation interventions work best? (editorial). Journal of Family Practice 60(7): 430-431, 2011. (17 refs.)

Makela P; Havio M; Seppa K. Alcohol-related discussions in health care: A population view. Addiction 106(7): 1239-1248, 2011. (41 refs.)

Aims: The present study aimed to evaluate the frequency and the target group of alcohol screening and brief interventions in health-care settings and how well this level of activity reflects public opinion. Design A general population survey. Setting and participants: A random sample of Finns aged 15-69 years with a 74% response rate (n = 2725). Measurements: Frequency counts were used to evaluate the level of activity. Logistic regression models were used to examine which groups were asked and advised about alcohol use and which groups considered it useful. Findings: More than 90% had positive attitudes towards being asked about their alcohol use. Of those who had been in contact with health care (n = 2062) in the 12 months before the survey, 33.3% had been asked about their alcohol use, being most often men, young, heavy drinkers and those of high socio-economic status. Thirty-seven per cent of those who had been asked were given advice, being most often heavy drinkers and those with a normal body mass index. However, 50% of heavy drinkers who had been asked about their alcohol use had not been advised about it. Of those who had been advised, 71.9% considered it useful, especially older subjects, and also including heavy episodic drinkers, although less than others. Conclusions: In Finland, the frequency of health-care professionals asking and giving advice on alcohol is relatively low. However, public opinion towards these discussions is positive. Our results encourage the support and uptake of systematic screenings and brief interventions in health-care settings.

Martin-Lujan F; Pinol-Moreso JL; Martin-Vergara N; Basora-Gallisa J; Pascual-Palacios I; Sagarra-Alamo R et al. Effectiveness of a structured motivational intervention including smoking cessation advice and spirometry information in the primary care setting: the ESPITAP study. BMC Public Health 11: e-article 859, 2011. (37 refs.)

Background: There is current controversy about the efficacy of smoking cessation interventions that are based on information obtained by spirometry. The objective of this study is to evaluate the effectiveness in the primary care setting of structured motivational intervention to achieve smoking cessation, compared with usual clinical practice. Methods Design: Multicentre randomized clinical trial with an intervention and a control group. Setting: 12 primary care centres in the province of Tarragona (Spain). Subjects of study: 600 current smokers aged between 35 and 70 years with a cumulative habit of more than 10 packs of cigarettes per year, attended in primary care for any reason and who did not meet any of the exclusion criteria for the study, randomly assigned to structured intervention or standard clinical attention. Intervention: Usual advice to quit smoking by a general practitioner as well as a 20-minute personalized visit to provide detailed information about spirometry results, during which FEV1, FVC, FEF 25-75% and PEF measurements were discussed and interpreted in terms of theoretical values. Additional information included the lung age index (defined as the average age of a non-smoker with the same FEV1 as the study participant), comparing this with the chronological age to illustrate the pulmonary deterioration that results from smoking. Measurements: Spirometry during the initial visit. Structured interview questionnaire administered at the primary care centre at the initial visit and at 12-month follow-up. Telephone follow-up interview at 6 months. At 12-month follow-up, expired CO was measured in patients who claimed to have quit smoking. Main variables: Smoking cessation at 12 months. Analysis: Data will be analyzed on the basis of "intention to treat" and the unit of analysis will be the individual smoker. Expected results: Among active smokers treated in primary care we anticipate significantly higher smoking cessation in the intervention group than in the control group. Discussion: Application of a motivational intervention based on structured information about spirometry results, improved abstinence rates among smokers seen in actual clinical practice conditions in primary care.

Mason M; Pate P; Drapkin M; Sozinho K. Motivational interviewing integrated with social network counseling for female adolescents: A randomized pilot study in urban primary care. Journal of Substance Abuse Treatment 41(2): 148-155, 2011. (47 refs.)

This study tested the efficacy of a brief preventive intervention for substance use and associated risk behaviors among female adolescent patients of an urban primary care health clinic. We integrated an evidenced-based motivational interviewing (MI) approach with a social network component to develop a 20-minute session, a social network intervention delivered in an MI-consistent style. Female adolescents (N = 28) 14 to 18 years old were recruited, provided consent/assent, were screened, and were randomly assigned to the treatment or control (no treatment) condition. The sample was 82% African American and 18% mixed race, with 32% living below the U.S. poverty line. At 1-month follow-up, teens in the treatment condition reported less trouble due to alcohol use, less substance use before sexual intercourse, less social stress, less offers for marijuana use, and increased readiness to start counseling compared with the teens in the control condition. Results provide support for socially based brief interventions with at-risk urban adolescents.

Massey SH; Norris L; Lausin M; Nwaneri C; Lieberman DZ. Identifying harmful drinking using a single screening question in a psychiatric consultation-liaison population. Psychosomatics 52(4): 362-366, 2011. (22 refs.)

Background: Harmful drinking is common in medical inpatients, yet commonly missed due in part to time pressures. A screening question about past year heavy drinking recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has been validated in primary care and emergency room settings. We tested the psychometric properties of a modified single screening question (SSQ) in hospitalized patients referred to a consultation-liaison service. Methods: A psychiatry attending (n = 40), a psychiatry resident (n = 30) and a medical student (n = 30) administered the SSQ, followed by a self-report 10-item Alcohol Use Disorders Identification Test (AUDIT) to a sample of 100 consultation-liaison patients who were able to give informed consent for participation. Results: Using the AUDIT as a reference, the sensitivity and specificity of the SSQ to detect harmful drinking in this sample were .96 and .82, respectively. Gender differences in specificity were not found. The single question also had a strong correlation with dependence (r(b) = .457, p < .001), and harmful use (r(b) = .620, p < .001) subscales of the AUDIT. Conclusion: The SSQ about past year heavy drinking can rapidly identify harmful drinking in alert nonpsychotic consultation-liaison patients. [Note: "The" question, after asking if someone sometimes drinks beer wine, or other alcoholic beverages is "Have you had five or more drinks (four or more for women) in a single day in the past year?". A response of yes is considered positive and indicating the need for a more comprehensive assessment.]

McCance-Katz EF; Satterfield J. SBIRT: A key to integrate prevention and treatment of substance abuse in primary care. American Journal on Addictions 21(2): 176-177, 2012. (10 refs.)

The 2009 National Survey on Drug Use and Health reported that 21.8 million, or 8%, of those over age 12 had used illicit substances in the past month, 23.7% (59.6 million) reported binge drinking, and 6.8% (17.1 million) reported regular heavy drinking. This makes substance abuse one of the most common medical disorders in the United States. Furthermore, at best only 10% of those in need of treatment, actual receiving treatment. A single screening question is recommended for primary care, community health settings, and emergency departments. The question is "in the past year, have you had any times when you had 5 (for women, 4) or more drinks at one sitting?" The authors discusses efforts by SAMHSA has launched a 17 site, medical residency training program to promote the core SBIRT clinical skills among physicians, with the goal of bringing one of the most common medical disorders into the medical mainstream.

McCarberg BH. Pain management in primary care: Strategies to mitigate opioid misuse, abuse, and diversion. Postgraduate Medicine 123(2): 119- 130, 2011. (74 refs.)

Pain is among the most common reasons patients seek medical attention, and the care of patients with pain is a significant problem in the United States. Acute pain (mild-to-moderate intensity) represents one of the most frequent complaints encountered by primary care physicians (PCPs) and accounts for nearly half of patient visits. However, the overall quality of pain management remains unacceptable for millions of US patients with acute or chronic pain, and underrecognition and undertreatment of pain are of particular concern in primary care. Primary care physicians face dual challenges from the emerging epidemics of undertreated pain and prescription opioid abuse. Negative impacts of untreated pain on patient activities of daily living and public health expenditures, combined with the success of opioid analgesics in treating pain provide a strong rationale for PCPs to learn best practices for pain management. These clinicians must address the challenge of maintaining therapeutic access for patients with a legitimate medical need for opioids, while simultaneously minimizing the risk of abuse and addiction. Safe and effective pain management requires clinical skill and knowledge of the principles of opioid treatment as well as the effective assessment of risks associated with opioid abuse, addiction, and diversion. Easily implementable patient selection and screening, with selective use of safeguards, can mitigate potential risks of opioids in the busy primary practice setting. Primary care physicians can become advocates for proper pain management and ensure that all patients with pain are treated appropriately.

McRae I; Yen LR; Gillespie J; Douglas K. Patient affiliation with GPs in Australia: Who is and who is not and does it matter? Health Policy 103(1): 16-23, 2011. (19 refs.)

Aims and rationale: Recent government reports have proposed voluntary enrolment with general practitioners for certain groups of patients to enhance their continuity of care. We examine which groups of patients are presently "de facto" affiliated with GPs, and whether affiliated patients are more likely to receive advice from their GPs on primary preventative matters such as weight, exercise and smoking. Methods: A nationally representative cross sectional survey of Australian residents aged 18 years or over was conducted via telephone in 2008. Data from 1146 participants were analysed in both tabular forms and with logistic regression. Findings: Most Australian adults are affiliated, de facto, with an individual GP or a GP practice (11% often go to different GPs). Factors associated with affiliation were patient age, education, satisfaction with their GP and urban or rural location. Patients with poor or fair self assessed health are relatively unlikely to be affiliated with a GP. Weak support was found for the hypothesis that affiliated patients were more likely to receive primary preventative advice on weight and diet and no support found in relation to exercise, smoking or alcohol consumption. Benefits to the community: The study suggests policy on voluntary patient enrolment should focus on providing continuity of care to those with poor health. If further studies confirm affiliation does not enhance preventive health advice, further policy interventions may be appropriate.

Meyer C; Ulbricht S; Gross B; Kastel L; Wittrien S; Klein G et al. Adoption, reach and effectiveness of computer-based, practitioner delivered and combined smoking interventions in general medical practices: A three-arm cluster randomized trial. Drug and Alcohol Dependence 121(1-2): 124-132, 2012. (43 refs.)

Background: Brief advice for smoking patients has not been sufficiently integrated in routine care. Computer-based interventions emerged as a time saving option that might help to exhaust the potential population impact of the general practice setting. Method: 151 practices were randomly assigned to one of three intervention programs consisting in the delivery of: (1) brief advice by the practitioner; (2) individually tailored computer-generated letters; or (3) a combination of both interventions. We assessed three dimensions of population impact: (1) adoption, i.e., the rate of practices participating in the program; (2) reach, measured as the number of interventions provided within 7 months; (3) effectiveness, measured as smoking abstinence at 12-months follow-up. Results: Among the practices, 70% adopted the program with no significant differences across study groups. Treatment was provided to 3086 adult smokers. Negative binomial regression analysis revealed that the number of interventions provided was higher in practices allocated to the tailored letter and combination intervention groups by 215% (p<.01) and 127% (p=.02), respectively, compared to the brief advice intervention group. Among the patients who received the combination of both intervention, the odds of point abstinence from smoking was increased by 65% (p=.02) and 32% (p=.01) compared to the brief advice and tailored letters intervention respectively. Comparing the number of abstinent patients at follow-up revealed that the tailored letter and combination interventions were superior to the brief advice intervention. Conclusions: Computer-based interventions alone or in addition to conventional practitioner-delivered advice can foster the participation of general medical practices in tobacco control.

Midmer D; Kahan M; Kim T; Ordean A; Graves L. Efficacy of a physicians' pocket guide about prenatal substance use: A randomized trial. Substance Abuse 32(4): 175-179, 2011. (13 refs.)

A pocket guide on management of substance use during pregnancy was developed by a group of Canadian care providers. One hundred and fifteen family medicine residents in 6 Canadian teaching sites were randomized to receive either the pocket guide or a paper summary on similar clinical topics, based on UpToDate, a comprehensive Web-based resource. At baseline, both groups completed a survey containing questions on beliefs, attitudes, experience, and training on pregnancy and substance use. Participants then answered 28 multiple choice questions about substance use in pregnancy, using either the pocket guide or UpToDate. Finally participants were asked to rate ease of use for the 2 resources. The results showed that the pocket guide group had higher knowledge scores than the UpToDate group overall and at each study site (61.27% vs. 42.86%, P < .001). The residents found the pocket guide easier to use than UpToDate (mean = 2.73 vs. 4.36, P < .001), and were more likely to want to use it again (96% for pocket card, 78% for UpToDate, P = .005). It is concluded that the pocket guide is a practical source of clinical information at point of care, particularly for "orphan" subjects such as substance use in pregnancy.

Miller PM; Book SW; Stewart SH. Medical treatment of alcohol dependence: A systematic review. (review). International Journal of Psychiatry in Medicine 42(3): 227-266, 2011. (103 refs.)

Objective: To summarize published data on pharmacologic treatments for alcohol dependence alone and in combination with brief psychosocial therapies that may be feasible for primary care and specialty medical settings. Methods: We conducted electronic searches of published original research articles and reviews in MEDLINE, SCOPUS, CINAHL, Embase, and PsychINFO. In addition, hand searches of reference lists of review articles, supplemental searches of internet references and contacts with experts in the field were conducted. Randomized controlled studies published between January 1960 and August 2010 that met our inclusion/exclusion criteria were included. Results: A total of 85 studies, representing 18,937 subjects, met our criteria for inclusion. The evidence base for oral naltrexone (6% more days abstinent than placebo in the largest study) and topiramate (prescribed off-label) (e.g., 26.2% more days abstinent than placebo in a recent study) is positive but modest. Acamprosate shows modest efficacy with recently abstinent patients, with European studies showing better results than U.S. ones. The evidence-base for disulfiram is equivocal. Depot naltrexone shows efficacy (25% greater reduction in rate of heavy drinking vs. placebo, in one of the largest studies) in a limited number of studies. Some studies suggest that patients do better with extensive psychosocial treatments added to medications while others show that brief support can be equally effective. Conclusions: Although treatment effects are modest, medications for alcohol dependence, in conjunction with either brief support or more extensive psychosocial therapy, can be effective in primary and specialty care medical settings.

Mitchell SG; Kelly SM; Gryczynski J; Myers CP; Jaffe JH; O'Grady KE et al. African American patients seeking treatment in the public sector: Characteristics of buprenorphine vs. methadone patients. Drug and Alcohol Dependence 122(1-2): 55-60, 2012. (17 refs.)

Background: To expand its public-sector treatment capacity, Baltimore City made buprenorphine treatment accessible to low-income, largely African American residents. This study compares the characteristics of patients entering methadone treatment vs. buprenorphine treatment to determine whether BT was attracting different types of patients. Methods: Participants consisted of two samples of adult heroin-dependent African Americans. The first sample was newly admitted to a health center or a mental health center providing buprenorphine (N = 200), and the second sample was newly admitted to one of two hospital-based methadone programs (N = 178). The Addiction Severity Index (ASI) and the Friends Supplemental Questionnaire were administered at treatment entry and data were analyzed with logistic regression. Results: BT participants were more likely to be female (p = .017) and less likely to inject (p = .001). Participants with only prior buprenorphine treatment experience were nearly five time more likely to enter buprenorphine than methadone treatment (p < .001). Those with experience with both treatments were more than twice as likely to enter BT (OR = 2.7, 95% Cl = 1.11-6.62; p = .028). In the 30 days prior to treatment entry, BT participants reported more days of medical problems (p = .002) and depression (p = .044), and were more likely to endorse a lifetime history of depression (p < .001). Conclusion: Methadone and buprenorphine treatment provided in the public sector may attract different patient subpopulations. Providing buprenorphine treatment through drug treatment programs co-located with a health and mental health center may have accounted for their higher rates of medical and psychiatric problems and appears to be useful in attracting a diverse group of patients into public-sector funded treatment.

Moraes CL; da Silva TDT; Reichenheim ME; Azevedo GL; Oliveira ASD; Braga JU. Physical violence between intimate partners during pregnancy and postpartum: A prediction model for use in primary health care facilities. Paediatric and Perinatal Epidemiology 25(5): 478-486, 2011. (50 refs.)

This article offers a simple predictive model of physical intimate partner violence (PIPV) to be used by primary health care (PHC) professionals. The sample comprised 811 mothers of children <5 months old attending PHC facilities in Rio de Janeiro, Brazil. A multinomial logit model was used. Measured by the Revised Conflict Tactics Scales, PIPV was classified in three levels (absence, at least one episode during pregnancy or postpartum, and presence in both periods). Socio-economic, demographic and life style variables were considered as potential predictors. Maternal age <20 years, an education of <8 years of schooling, raising >2 children under 5, tobacco smoking, alcohol misuse and illicit drug use by the mother and/or partner, and perception of baby's ill-health were identified as predictors of PIPV. The model-projected prevalence of PIPV for pregnancy and/or postpartum was just 10.1% in the absence of these characteristics, whereas this increased to 96.4% when all the seven characteristics were present. Child, maternal and family characteristics greatly increase the likelihood of PIPV and could be used together as screening indicators.

Morasco BJ; Duckart JP; Dobscha SK. Adherence to clinical guidelines for opioid therapy for chronic pain in patients with substance use disorder. Journal of General Internal Medicine 26(9): 965-971, 2011. (42 refs.)

BACKGROUND: Patients with chronic non-cancer pain (CNCP) have high rates of substance use disorders (SUD). SUD complicates pain treatment and may lead to worse outcomes. However, little information is available describing adherence to opioid treatment guidelines for CNCP generally, or guideline adherence for patients with comorbid SUD. OBJECTIVE: Examine adherence to clinical guidelines for opioid therapy over 12 months, comparing patients with SUD diagnoses made during the prior year to patients without SUD. DESIGN: Cohort study. PARTICIPANTS: Administrative data were collected from veterans with CNCP receiving treatment within a Veterans Affairs regional healthcare network who were prescribed chronic opioid therapy in 2008 (n = 5814). KEY RESULTS: Twenty percent of CNCP patients prescribed chronic opioid therapy had a prior-year diagnosis of SUD. Patients with SUD were more likely to have pain diagnoses and psychiatric comorbidities. In adjusted analyses, patients with SUD were more likely than those without SUD to have had a mental health appointment (29.7% versus 17.2%, OR = 1.49, 95% CI = 1.26-1.77) and a urine drug screen (UDS) (47.0% versus 18.2%, OR = 3.53, 95% CI = 3.06-4.06) over 12 months. There were no significant differences between groups on receiving more intensive treatment in primary care (63.4% versus 61.0%), long-acting opioids (26.9% versus 26.0%), prescriptions for antidepressants (88.2% versus 85.8%, among patients with depression), or participating in physical therapy (30.6% versus 28.6%). Only 35% of patients with SUD received substance abuse treatment. CONCLUSIONS: CNCP patients with SUD were more likely to have mental health appointments and receive UDS monitoring, but not more likely to participate in other aspects of pain care compared to those without SUD. Given data suggesting patients with comorbid SUD may need more intensive treatment to achieve improvements in pain-related function, SUD patients may be at high risk for poor outcomes.

Moriarty HJ; Stubbe MH; Chen L; Tester RM; Macdonald LM; Dowell AC et al. Challenges to alcohol and other drug discussions in the general practice consultation. Family Practice 29(2): 213-222, 2012. (38 refs.)

Background. There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. Aim. To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. Design. Analysis of video-recorded primary care consultations. Setting. New Zealand General Practice. Methods. Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. Results. AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. Conclusions. Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

Mulia N; Schmidt LA; Ye Y; Greenfield TK. Preventing disparities in alcohol screening and brief intervention: The need to move beyond primary care. Alcoholism: Clinical and Experimental Research 35(9): 1557-1560, 2011. (43 refs.)

The alcohol treatment field has focused on promoting screening and brief intervention (SBI) in medically based settings, particularly primary care. In this Commentary, we consider the potential unintended consequences for disparities in access to care for alcohol problems. National data show significant racial/ethnic and socioeconomic differences in the rates at which at-risk drinkers and persons with alcohol use disorders come into contact with primary care providers. This suggests that implementing SBI in mostly primary care settings could inadvertently widen the gap in alcohol-related health disparities. To ensure that all populations in need benefit from this evidence-based treatment, SBI should be considered and adapted for a wider range of service venues, including Federally Qualified Health Centers and venues frequented by racial/ethnic minorities and the uninsured.

Murnion B. Management of opioid substitution therapy during medical intervention. Internal Medicine Journal 42(3): 242-246, 2012. (28 refs.)

Opioid substitution therapy (OST) for opioid dependence is common, and injection drug users have significant medical and psychiatric comorbidity. Many physicians will encounter OST patients in their usual practice. This article provides guidance on management of common clinical problems in this population, including OST management in hepatic failure, respiratory disease, pain management and potential drug interactions.

Myers BJ. Primary health care for people who inject drugs in low and middle income countries. (editorial). International Journal of Drug Policy 23(2): 105-106, 2012. (6 refs.)

Navarro HJ; Shakeshaft A; Doran CM; Petrie DJ. The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: Evidence from rural Australia. Addictive Behaviors 36(12): 1191-1198, 2011. (65 refs.)

Objective: This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice. Method: A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia. Findings: Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and Blare increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197. Conclusion: These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.

Niccols A; Milligan K; Sword W; Thabane L; Henderson J; Smith A. Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes. (review). Harm Reduction Journal 9: e-article 14, 2012. (50 refs.)

Background: Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes. Objectives: As part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes. Methods: Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes. Results: There were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, ds = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health. Conclusions: This is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues.

Nilsen P; McCambridge J; Karlsson N; Bendtsen P. Brief interventions in routine health care: A population-based study of conversations about alcohol in Sweden. Addiction 106(10): 1748-1756, 2011. (25 refs.)

Abstract: Aims To investigate how brief alcohol interventions are delivered in routine practice in the Swedish health-care system. Design, setting and participants: A cross-sectional sample of 6000 individuals representative of the adult population aged 18-64 years registered in the Swedish total population register was drawn randomly. Data were collected in 2010 by means of a mail questionnaire. The response rate was 54%. Measurements The questionnaire consisted of 27 questions, of which 15 variables were extracted for use in this study. Whether alcohol had been discussed and the duration, contents, experiences and effects of any conversations about alcohol, as reported by patients themselves, were assessed. Findings: Sixty-six per cent of the respondents had visited health-care services in the past 12 months and 20% of these had had one or more conversations about alcohol during these visits (13% of the population aged 18-64 years). The duration of the conversations was generally brief, with 94% taking less than 5 minutes, and were not experienced as problematic. The duration, contents, experiences and effects of these conversations generally varied between abstainers, moderate, hazardous and excessive drinkers. Twelve per cent of those having a conversation about alcohol reported that it led to reduced alcohol consumption. Reduced alcohol consumption was more likely when conversations lasted for 1-10 minutes rather than less than 1 minute and included advice on how to reduce consumption. Conclusions: Population survey data in Sweden suggest that when health-care professionals give brief advice to reduce alcohol consumption, greater effects are observed when the advice is longer and includes advice on how to achieve it.

Ong MK; Zhou Q; Sung HY. Primary care providers advising smokers to quit: Comparing effectiveness between those with and without alcohol, drug, or mental disorders. Nicotine & Tobacco Research 13(12): 1193-1201, 2011. (41 refs.)

Individuals with alcohol, drug, or mental (ADM) disorders combined make up over 40% of all smokers in the U.S. Primary care providers (PCPs) play an important role in smoking cessation counseling, but their effectiveness with this population is unclear. This study evaluated the effectiveness of PCP smoking cessation counseling for smokers with ADM disorders. Probit regressions conducted in 2009-2010 examined the relationship between past year PCP smoking cessation counseling and successful quitting among 1,356 adults who reported smoking in the 1998-1999 Community Tracking Study survey and who reported seeing a PCP in the past year in the follow-up 2000-2001 Healthcare for Communities Survey. Past year PCP exercise counseling was used as an instrumental variable for past year PCP smoking cessation counseling to account for potential hidden bias between smoking status and receipt of smoking cessation counseling. Smokers with and without ADM disorders were equally likely to receive smoking cessation counseling (72.9% vs. 69.9%). Using the instrumental variable approach, smoking cessation counseling by PCPs was significantly associated (p < .01) with quitting among both groups. Predicted probabilities of quitting without smoking cessation counseling were 6.0% for smokers with ADM disorders and 10.5% for smokers without ADM disorders. Predicted probabilities of quitting with smoking cessation counseling were 31.3% for smokers with ADM disorders and 34.9% for smokers without ADM disorders. This study shows that PCPs can help smokers with ADM disorders successfully quit. These smokers should be targeted for smoking cessation counseling to reduce the health burden of tobacco.

Ostroff JS; Shuk E; Krebs P; Lu WH; Burkhalter J; Cortez-Weir J et al. Qualitative evaluation of a new tobacco cessation training curriculum for patient navigators. Journal of Cancer Education 26(3): 427-435, 2011. (38 refs.)

Treatments for tobacco dependence exist but are underutilized, particularly among low-income and minority smokers. Patient navigation has been shown to help patients overcome barriers to quality care. In preparation for testing the feasibility of integrating tobacco cessation patient navigation into primary care, this paper describes the development and qualitative evaluation of a new curriculum for training patient navigators to address cessation treatment barriers faced by low-income, minority smokers who are advised to quit by their physicians. Thematic text analysis of transcripts obtained from focus groups with experienced patient navigators (n = 19) was conducted. Participants endorsed patient navigation as a relevant strategy for addressing tobacco cessation treatment barriers and made several recommendations regarding the knowledge, core competencies, and skills needed to conduct tobacco cessation patient navigation. This curriculum could be used by existing patient navigation training centers or made available as a self-guided continuing education program for experienced navigators who wish to expand their navigation interventions to include a tobacco cessation focus. [Note: A "navigator" serves as a coordinator/case manager, a patient advocate, and linking clients in primary care with community resources.]

Ozer EM; Adams SH; Orrell-Valente JK; Wibbelsman CJ; Lustig JL; Millstein SG et al. Does delivering preventive services in primary care reduce adolescent risky behavior? Journal of Adolescent Health 49(5): 476-482, 2011. (39 refs.)

Purpose: To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits. Methods: The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14-15 years. Results: The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [ NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS). Conclusions: The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.

Palmer RC; McKinney S. Health care provider tobacco cessation counseling among current African American tobacco users. Journal of the National Medical Association 103(8): 660-667, 2011. (41 refs.)

Tobacco use is the leading cause of preventable mortality and morbidity in the United States. Patients advised to quit use of tobacco products by their health care providers are more likely to quit, yet it has been documented that patients are not receiving this advice. The aim of this study was to investigate whether or not current African American tobacco users were receiving provider-initiated advice to quit. A cross-sectional survey identified 245 self-reported African American tobacco users residing in Maryland. Study variables collected included sociodemographics,, access to care, smoking status, and assessed if tobacco cessation counseling was ever provided. Among those surveyed, only 42% reported ever being counseled to quit tobacco use and, of those who had a recent clinical encounter (within the past year), only 20% reported being counseled. Multivariate logistic regression identified that having a regular source of health care, living in an urban setting, and being female increased chances of being advised to quit tobacco use. Overall, findings indicate that African Americans are not being screened or receiving cessation counseling as recommended by leading health agencies. Health care provider training to promote better integration of tobacco screening and tobacco cessation counseling during the patient encounter is needed.

Paulozzi LJ; Weisler RH; Patkar AA. A national epidemic of unintentional prescription opioid overdose deaths: How physicians can help control it. (editorial). Journal of Clinical Psychiatry 72(5): 589-592, 2011. (23 refs.)

Both the usage of prescription drugs such as opioid analgesics and benzodiazepines and overdoses involving them have increased dramatically in the United States since the 1990s. Patients using these drugs often have a combination of painful conditions, substance abuse, and other forms of mental illness. Psychiatrists and many primary care physicians might not be familiar with existing evidence-based guidelines for opioid prescribing or with programs designed to reduce the abuse of prescription drugs such as state prescription drug monitoring programs. Psychiatrists need to be informed regarding this problem to partner effectively with both pain specialists and primary care providers in their community.

Payne M; Gething M; Moore AA; Reid MC. Primary care providers' perspectives on psychoactive medication disorders in older adults. American Journal of Geriatric Pharmacotherapy 9(3): 164-172, 2011. (29 refs.)

Background: Compared with younger adults, older adults consume a disproportionate percentage of pain and sleep medications. Some studies have reported that psychoactive medication misuse and abuse in older populations is a significant problem. Objectives: The aim of this study was to understand the perspective of primary care providers (PCPs) regarding the extent and clinical presentations of misuse and abuse of psychoactive medications in older patients and to explore PCPs' perceived barriers to identifying affected individuals. Methods: Seventeen physicians and 5 nurse practitioners from 2 ambulatory care practices serving older adults in New York City participated in this study. Six focus group discussions were audiotaped and transcribed. Two raters coded transcripts to identify recurring themes. Qualitative analysis software was employed for data coding and sorting purposes. Results: Although PCPs indicated that only a small percentage of older patients were actively misusing or abusing their psychoactive medications (average estimate given by providers, 8%), they felt that these patients placed significant time burdens on them. Perceived risk factors included psychiatric disorders, previous substance abuse history, and cognitive impairment, but many PCPs found it impossible to predict which patients were at increased risk. PCPs identified multiple barriers to identifying affected patients, including lack of communication (between provider and patient, provider and patients' caregivers, and between different providers), nonspecific symptoms, and the lack of a clear definition of misuse and abuse. Conclusions: The lack of a clear definition, absence of well-defined risk factors, and ambiguous clinical manifestations of psychoactive medication misuse and abuse present substantial barriers to diagnosis. A standard, age-appropriate definition could help PCPs establish a diagnosis, clarify what constitutes appropriate psychoactive medication use, define the extent of the problem, and pave the way for the development of effective screening and diagnostic tools.

Pennay A; Lubman DI; MacLean S. Risky drinking among young Australians: Causes, effects and implications for GPs. Australian Family Physician 40(8): 584-588, 2011. (29 refs.)

Background: Rates of risky drinking among young Australians have increased substantially over the past 2 decades, resulting in significant community concern. Objective: To explore the social, cultural and economic contexts that underlie risky drinking among young people and the implications of these for general practitioners. Discussion: Effective strategies for reducing alcohol related harm among young people must be developed in the context of the social and cultural forces to which risky drinking is inextricably linked. It is important that GPs not only play the role of health provider (by identifying risky drinking where possible and providing harm reduction advice), but also act as public health advocates, using their position as respected health experts to encourage a shift in alcohol policy, legislation, marketing and promotion.

Pillai R; Bhangu N; Narayanan M; Yoong W. A demographic study to profile non-attenders at a gynaecology outpatient clinic. Journal of Obstetrics and Gynaecology 32(2): 156, 2012. (12 refs.)

Missed outpatient appointments result in the inefficient utilisation of resources and have secondary effects on the health of the non-attenders, as well as on other patients who have to wait longer for their appointments. The first part of the study involved retrospective analysis of trends of non-attendance based on a computerised database of all gynaecology appointments over 12 months. The second comprised a prospective case-control study in which women who missed their gynaecology outpatient appointments (index cases) over 2 months were compared with patients who attended the same clinics matched for indication for referral (control cases). The overall non-attendance rate over 12 months was 16.1%, of whom 42% were recurrent non-attenders. Data from 105 defaulters were compared with 105 non-defaulters who attended the same clinics. Defaulters were significantly younger, single or separated and were more likely to be 'follow-ups' rather than new cases (all p < 0.05). Longer intervals between the appointment letter and actual appointment date was significantly related to non-attendance (p = 0.01) and there was a trend to a greater degree of smoking and alcohol ingestion in the defaulter group (p = 0.059). Comparison of other variables such as severity of symptoms, parity, source of referral and fluency of English did not reach statistical significance (p > 0.05). This prospective study has demonstrated certain profiles which are common to defaulters and which can be used to develop strategies to minimise nonattendance. Examples include reducing the time interval between sending the appointment letter and actual appointment date and selectively over-booking younger, single women who smoke.

Reddon H; Wood E; Tyndall M; Lai C; Hogg R; Montaner J; Kerr T. Use of North America's first medically supervised safer injecting facility among HIV-positive injection drug users. AIDS Education And Prevention 23(5): 412-422, 2011. (49 refs.)

The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV-specific services such as disease monitoring and the provision of antiretroviral therapy.

Reid SC; Kauer SD; Hearps SJC; Crooke AHD; Khor AS; Sanci LA et al. A mobile phone application for the assessment and management of youth mental health problems in primary care: A randomised controlled trial. BMC Family Practice 12: e-article 131, 2011. (61 refs.)

Background: Over 75% of mental health problems begin in adolescence and primary care has been identified as the target setting for mental health intervention by the World Health Organisation. The mobiletype program is a mental health assessment and management mobile phone application which monitors mood, stress, coping strategies, activities, eating, sleeping, exercise patterns, and alcohol and cannabis use at least daily, and transmits this information to general practitioners (GPs) via a secure website in summary format for medical review. Methods: We conducted a randomised controlled trial in primary care to examine the mental health benefits of the mobiletype program. Patients aged 14 to 24 years were recruited from rural and metropolitan general practices. GPs identified and referred eligible participants (those with mild or more mental health concerns) who were randomly assigned to either the intervention group (where mood, stress, and daily activities were monitored) or the attention comparison group (where only daily activities were monitored). Both groups self-monitored for 2 to 4 weeks and reviewed the monitoring data with their GP. GPs, participants, and researchers were blind to group allocation at randomization. Participants completed pre-, post-, and 6-week post-test measures of the Depression, Anxiety, Stress Scale and an Emotional Self Awareness (ESA) Scale. Results: Of the 163 participants assessed for eligibility, 118 were randomised and 114 participants were included in analyses (intervention group n = 68, comparison group n = 46). Mixed model analyses revealed a significant group by time interaction on ESA with a medium size of effect suggesting that the mobiletype program significantly increases ESA compared to an attention comparison. There was no significant group by time interaction for depression, anxiety, or stress, but a medium to large significant main effect for time for each of these mental health measures. Post-hoc analyses suggested that participation in the RCT lead to enhanced GP mental health care at pre-test and improved mental health outcomes. Conclusions: Monitoring mental health symptoms appears to increase ESA and implementing a mental health program in primary care and providing frequent reminders, clinical resources, and support to GPs substantially improved mental health outcomes for the sample as a whole.

Reisinger HS; Brackett RH; Buzza CD; Paez MBW; Gourley R; Vander Weg MW et al. "All the Money in the World ..." patient perspectives regarding the influence of financial incentives. Health Services Research 46(6, part 1): 1986-2004, 2011. (39 refs.)

Objective. To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period. Study Design. Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call. Data Collection Methods. Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis. Principle Findings. Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care. Conclusion. The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings. [Note: contingency management is used in alcohol and drug use treatment.]

Rigotti NA; Bitton A; Kelley JK; Hoeppner BB; Levy DE; Mort E. Offering population-based tobacco treatment in a healthcare setting: A randomized controlled trial. American Journal of Preventive Medicine 41(5): 498-503, 2011. (20 refs.)

Background: The healthcare system is a key channel for delivering treatment to tobacco users. Brief clinic-based interventions are effective but not reliably offered. Population management strategies might improve tobacco treatment delivery in a healthcare system. Purpose: To test the effectiveness of supplementing clinic-based care with a population-based direct-to-smoker (DTS) outreach offering easily accessible free tobacco treatment. Design: Randomized controlled trial, conducted in 2009-2010, comparing usual clinical care to usual care plus DTS outreach. Setting/participants: A total of 590 smokers registered for primary care at a community health center in Revere MA. Interventions: Three monthly letters offering a free telephone consultation with a tobacco coordinator who provided free treatment including up to 8 weeks of nicotine patches (NRT) and proactive referral to the state quitline for multisession counseling. Main outcome measures: Use of any tobacco treatment (primary outcome) and tobacco abstinence at the 3-month follow-up; cost per quit. Results: Of 413 eligible smokers, 43 (10.4%) in the DTS group accepted the treatment offer; 42 (98%) requested NRT and 30 (70%) requested counseling. In intention-to-treat analyses adjusted by logistic regression for age, gender, race, insurance, diabetes, and coronary heart disease, a higher proportion of the DTS group, compared to controls, had used NRT (11.6% vs 3.9%, OR = 3.47; 95% CI = 1.52, 7.92) or any tobacco treatment (14.5% vs 7.3%, OR = 1.95, 95% CI = 1.04, 3.65) and reported being tobacco abstinent for the past 7 days (5.3% vs 1.1%, OR = 5.35, 95% CI = 1.23, 22.32) and past 30 days (4.1% vs 0.6%, OR = 8.25, 95% CI = 1.08, 63.01). The intervention did not increase smokers' use of counseling (1.7% vs 1.1%) or non-NRT medication (3.6% vs 3.9%). Estimated incremental cost per quit was $464. Conclusions: A population-based outreach offering free tobacco treatment to smokers in a health center was a feasible, cost-effective way to increase the reach of treatment (primarily NRT) and to increase short-term quit rates.

Sanju G; Gerada C. Problem gamblers in primary care: can GPs do more? (editorial). British Journal of General Practice 61(585): 248- 249, 2011. (12 refs.)

Sansone RA; Lam C; Wiederman MW. Prevalence of criminal behaviors in an internal-medicine-resident clinic population. Southern Medical Journal 104(10): 695-698, 2011. (16 refs.)

Objective: Few, if any, US studies have examined rates of criminal behaviors among patients in clinical samples. According to findings from non-US studies, mostly in psychiatric samples, rates of criminal behavior are higher than in the general population. In this study, we examined the prevalence of criminal behaviors in an internal medicine outpatient sample from a resident-provider clinic. Method: In a consecutive sample of internal medicine outpatients, 380 participants were surveyed in October of 2010 regarding 27 criminal offenses as delineated by the crime categorization schema used by the Federal Bureau of Investigation. Results: In this sample, 22.1% reported at least one criminal charge. The most commonly self-reported criminal charge was driving under the influence of alcohol or drugs (10.3%), followed by disorderly conduct (7.1%), drug abuse violations (5.8%), simple assault (5.3%), drunkenness (4.5%), and aggravated assault (3.2%). Conclusions: Like previous non-US studies among psychiatric samples, there appears to be a higher prevalence of criminal behavior among outpatients in an internal medicine training clinic than in the general population. These behaviors may be inter-related through alcohol/substance-use disorders.

Seppa K. Primary health care and alcohol. (editorial). Zdravstveno Varstvo 50(3): 143-147, 2011. (39 refs.)

In his famous novel 'Anna Karenina' Konstantin Levin, a farmer who is commonly considered to represent the author Leo Tolstoy himself, listens to another farmer's opinions on the land reform. He highly respects these opinions which, as he says, 'had been brought not by a desire of finding some exercise for an idle brain, but a thought which had grown up out of the conditions of his life'. Researchers and policy makers, far from the realities of primary health care, seem to be more interested in brief alcohol interventions for hazardous drinkers than do general practitioners or other professionals working in this setting. Should brief intervention be removed to some other setting, buried forever as not being suitable for real life, or would it just now be perfect time for general practitioners and nurses in primary health care to take command of brief interventions and make it suitable for their own setting?

Sheridan J; Butler R. Prescription drug misuse in New Zealand: Challenges for primary health care professionals. Research in Social & Administrative Pharmacy 7(3): 281-293, 2011. (63 refs.)

Background: Prescription drug misuse (PDM) is an international phenomenon. Prescription drugs sought for this purpose are often obtained through the primary health care network. Objectives: This study aimed to explore the challenges faced by community pharmacists (CPs) and general practitioners (GPs) when faced with the issue of "drug-seeking" and PDM. This forms part of a larger study of PDM issues for primary health care practitioners. Methods: Qualitative interviews were carried out in New Zealand with 17 GPs and 16 CPs, purposively sampled to provide information from a variety of demographic and work environments. Interviews were tape-recorded, transcribed verbatim, and a thematic analysis conducted. Data collection took place between June 2007 and January 2008, and interviewees were offered an NZ$30 voucher in recognition of their contribution to the research. Results: GPs and CPs faced a series of challenges in managing PDM, including identification of PDM, dealing with requests for inappropriate requests for psychoactive prescription drugs, verifying the legitimacy of requests and managing threatening behaviors. Specific issues were faced by rural practitioners, female practitioners and by locums and part-time staff. In particular, some participants reported feeling emotionally stressed after unpleasant drug-seeking incidents and some acknowledged that they may have missed identifying some drug-seeking because of lack of knowledge, "drug-seekers" sophisticated strategies, or patients falling outside of their image of the archetypal "drug-seeker." Conclusion: This study demonstrated that PDM can be an issue for primary health care practitioners, and it can cause disruption to their work. Training in how to better manage threatening and escalating incidents may be useful as would increasing the level of awareness of PDM issues among health professional students.

Singh RR; Ambekar A. Opioid substitution treatment in a public health setting: A collaboration between hospitals and NGOs in the Punjab. (editorial). International Journal of Drug Policy 23(2): 170-171, 2012. (0 refs.)

Smit F; Lokkerbol J; Riper H; Majo MC; Boon B; Blankers M. Modeling the cost-effectiveness of health care systems for alcohol use disorders: How implementation of e-health interventions improves cost-effectiveness. Journal of Medical Internet Research 13(3): e56, 2011. (38 refs.)

Background: Informing policy decisions about the cost-effectiveness of health care systems (ie, packages of clinical interventions) is probably best done using a modeling approach. To this end, an alcohol model (ALCMOD) was developed. Objective: The aim of ALCMOD is to estimate the cost-effectiveness of competing health care systems in curbing alcohol use at the national level. This is illustrated for scenarios where new eHealth technologies for alcohol use disorders are introduced in the Dutch health care system. Method: ALCMOD assesses short-term (12-month) incremental cost-effectiveness in terms of reductions in disease burden, that is, disability adjusted life years (DALYs) and health care budget impacts. Results: Introduction of new eHealth technologies would substantially increase the cost-effectiveness of the Dutch health care system for alcohol use disorders: every euro spent under the current system returns a value of about the same size ((sic) 1.08, ie, a "surplus" of 8 euro cents) while the new health care system offers much better returns on investment, that is, every euro spent generates (sic) 1.62 in health-related value. Conclusion: Based on the best available evidence, ALCMOD's computations suggest that implementation of new eHealth technologies would make the Dutch health care system more cost-effective. This type of information may help (1) to identify opportunities for system innovation, (2) to set agendas for further research, and (3) to inform policy decisions about resource allocation.

Smith DE. Prescribing practices and the prescription drug epidemic: Physician intervention strategies. Journal of Psychoactive Drugs 44(1): 68-71, 2012. (21 refs.)

Prescription drug abuse is increasingly recognized as the United States' fastest growing drug problem, rising dramatically since the early 2000s, and particularly affecting adolescents and young adults. Federal officials are urging legislation to educate physicians about the use and effects of potent narcotics, which are increasingly being prescribed for chronic pain. ASAM developed strategies in the 1980s to identify the small minority of misprescribers and focused educational and retraining efforts on these individuals. As health reform and more prevalent pain management put more primary care physicians in a gatekeeper role to manage the medical care of addicts, these clinicians must become aware of the abuse potential of the powerful narcotics they prescribe. Increased reference to state-maintained controlled medication databases can also reduce misprescribing.

Sokka T; Pincus T. Poor physical function, pain and limited exercise: Risk factors for premature mortality in the range of smoking or hypertension, identified on a simple patient self-report questionnaire for usual care. BMJ Open 1: e-000070, 2011. (38 refs.)

Objective: To analyse poor physical function, pain, limited exercise and smoking, assessed in a patient-friendly self-report questionnaire format that has been completed by every patient at every visit over 20-30+/-14years in the authors' and other usual care settings, to predict 5-year mortality in a general older population. Methods: An extended version of a Multidimensional Health Assessment Questionnaire was mailed to 2000 subjects in Finland, identified as a randomly selected control cohort for a rheumatoid arthritis cohort. The questionnaire included queries concerning baseline physical function, pain, exercise and smoking status, identical to the clinic version, as well as age and 25 medical conditions. Five-year survival was analysed according to descriptive statistics, Kaplan-Meier curves and Cox regressions. Results: The questionnaire was returned by 1523 subjects (76%). Five-year survival was 94% in all subjects, 98% in subjects with no disease or no acutely life-threatening disease, and 17% in subjects with an acutely life-threatening disease. Hazard ratios (HRs) for 5-year mortality were 3.5 for poor physical function, 2.2 for pain, 5.2 for limited exercise and 4.6 for smoking (p<0.01); 5-year survivals were 93%, 97%, 93% and 95%, respectively, compared with 91% for hypertension. Each of the four patient history variables predicted mortality at higher levels in subjects who reported no versus one or more acutely life-threatening conditions. Conclusions: Poor physical function, pain, limited exercise and smoking can be assessed systematically on a simple standard Multidimensional Health Assessment Questionnaire, to identify potentially modifiable risk factors for premature mortality in the infrastructure of usual medical care and health maintenance.

Spak F. Commentary on Makela et al. (2011): How many patients must be asked about alcohol before it is enough? (editorial). Addiction 106(7): 1249-1250, 2011. (9 refs.)

Spata J; Kelsberg G; Safranek S. Does office spirometry improve quit rates in smokers? (editorial). Journal of Family Practice 59(10): 593-594, 2010. (7 refs.)

Srivastava A; Kahan M; Jiwa A. Prescription opioid use and misuse: Piloting an educational strategy for rural primary care physicians. Canadian Family Physician 58(4): E210-E216, 2012. (31 refs.)

Objective: To evaluate the feasibility and effectiveness of a multifaceted educational intervention to improve the opioid prescribing practices of rural family physicians in a remote First Nations community. Design: Prospective cohort study. Setting: Sioux Lookout, Ont. Participants: Family physicians. Interventions: Eighteen family physicians participated in a 1-year study of a series of educational interventions on safe opioid prescribing. Interventions included a main workshop with a lecture and interactive case discussions, an online chat room, video case conferencing, and consultant support. Main outcome measures: Responses to questionnaires at baseline and after 1 year on knowledge, attitudes, and practices related to opioid prescribing. Results: The main workshop was feasible and was well received by primary care physicians in remote communities. At 1 year, physicians were less concerned about getting patients addicted to opioids and more comfortable with opioid dosing. Conclusion: Multifaceted education and consultant support might play an important role in improving family physician comfort with opioid prescribing, and could improve the treatment of chronic pain while minimizing the risk of addiction.

Staiger PK; Thomas AC; Ricciardelli LA; McCabe MP. Identifying depression and anxiety disorders in people presenting for substance use treatment. Medical Journal of Australia 195(3, supplement): S60-S63, 2011. (18 refs.)

Objective: To identify the type and proportion of depressive and related mental health disorders in a group of individuals seeking outpatient treatment at an alcohol and other drug (AOD) service. Design, setting and participants: A cross-sectional study using diagnostic interviews with 95 participants (56 men, 39 women) seeking treatment from an AOD service. Main outcome measures: Mental health and substance disorders were measured using the Composite International Diagnostic Interview, Posttraumatic Stress Disorder Checklist, Beck Depression Inventory, and State Trait Anxiety Inventory (Trait Version). Results: This was a complex group with addiction, mental health and physical health conditions; 76% had a depressive disorder and 71% had an anxiety disorder. Most were diagnosed with at least two mental health disorders and 25% were diagnosed with four or more different disorders. Alcohol and cannabis use were the most commonly diagnosed AOD disorders. Further, those diagnosed with a drug use disorder reported significantly higher levels of depression compared with those with an alcohol-only disorder. Finally, 60% of the sample reported chronic health conditions, with over one-third taking medication for a physical condition on a regular basis. Conclusions: Primary care providers such as general practitioners are likely to be increasingly called on to assess, treat and/or coordinate care of patients with AOD disorders. We show that this group will likely present to their GP with more than one mental health disorder in addition to acute and chronic physical health conditions.

Starrels JL; Becker WC; Weiner MG; Li X; Heo M; Turner BJ. Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. Journal of General Internal Medicine 26(9): 958-964, 2011. (53 refs.)

Background/Objective: Experts recommend close oversight of patients receiving opioid analgesics for chronic non-cancer pain (CNCP), especially those at increased risk of misuse. We hypothesized that physicians employ opioid risk reduction strategies more frequently in higher risk patients. Design: Retrospective cohort using electronic medical records. Participants: Patients on long-term opioids (a parts per thousand yen3 monthly prescriptions in 6 months) treated for CNCP in eight primary care practices. Main Results: We examined three risk reduction strategies: (1) any urine drug test; (2) regular office visits (at least once per 6 months and within 30 days of modifying opioid treatment); and (3) restricted early refills (one or fewer opioid refills more than a week early). Risk factors for opioid misuse included: age < 45 years old, drug or alcohol use disorder, tobacco use, or mental health disorder. Associations of risk factors with each outcome were assessed in non-linear mixed effects models adjusting for patient clustering within physicians, demographics and clinical factors. Main results: Of 1,612 patients, 8.0% had urine drug testing, 49.8% visited the office regularly, and 76.6% received restricted (one or fewer) early refills. Patient risk factors were: age < 45 (29%), drug use disorder (7.6%), alcohol use disorder (4.5%), tobacco use (16.1%), and mental health disorder (48.4%). Adjusted odds ratios (AOR) of urine drug testing were significantly increased for patients with a drug use disorder (3.18; CI 1.94, 5.21) or a mental health disorder (1.73; CI 1.14, 2.65). However, the AOR for restricted early refills was significantly decreased for patients with a drug use disorder (0.56; CI 0.34, 0.92). After adjustment, no risk factor was significantly associated with regular office visits. An increasing number of risk factors was positively associated with urine drug testing (p < 0.001), but negatively associated with restricted early refills (p = 0.009). Conclusion: Primary care physicians' adoption of opioid risk reduction strategies is limited, even among patients at increased risk of misuse.

Stone L. Explaining the unexplainable: Crafting explanatory frameworks for medically unexplained symptoms. Australian Family Physician 40(6): 440-444, 2011. (69 refs.)

Background: Patients with multiple medically unexplained symptoms are common in general practice. Comorbid depression, anxiety, substance abuse and significant psychosocial stressors are common. It can be challenging to find a balance between excluding and treating organic causes and overinvestigating and overtreating. Objective: This article provides the general practitioner with a suggested framework for explaining multiple medically unexplained symptoms to patients. Discussion: An adequate explanation of the problem is important. General practitioners can use a number of explanatory models, including reassurance, somatisation and narrative techniques. Sometimes a solution to a specific problem is available and may involve referral to other health professionals. In many cases the more important management strategy may be to provide supportive care by being with the sufferer and acknowledging the suffering, without succumbing to the urge to fix the problem. General practitioners have a unique role in supporting patients who cope with symptoms, but without a clear medical diagnosis.

Sullivan LE; Tetrault JM; Braithwaite RS; Turner BJ; Fiellin DA. A meta-analysis of the efficacy of nonphysician brief interventions for unhealthy alcohol use: implications for the patient-centered medical home. American Journal on Addictions 20(4): 343-356, 2011. (47 refs.)

Brief physician interventions can reduce alcohol consumption. Physicians may not have the time to provide brief interventions, and it is unclear whether nonphysicians can do so effectively. We conducted a systematic review and meta-analysis to examine the efficacy of brief interventions by non-physician clinicians for unhealthy alcohol use. We searched the English-language literature in MEDLINE and other databases covering the domains of alcohol problems, primary care, nonphysician, and brief interventions. Studies of brief interventions delivered at least in part by nonphysicians in primary care and examining drinking outcomes were included. Sensitivity analyses examined the effect of excluding studies that contributed disproportionately to the heterogeneity of results. Thirteen studies, conducted 1996-2008, met our criteria. Seven studies with a total of 2,633 patients were included in the meta-analysis. Nonphysician interventions were associated with 1.7 (95% confidence interval [CI] = -.03 to -3.5) fewer standard drinks per week than control conditions (p = .054). Excluding the one study that increased heterogeneity, the effect was smaller but reached statistical significance; nonphysician counseling was associated with 1.4 (95% CI = .3-2.4) fewer standard drinks per week compared to control (p = .012). Nonphysician brief interventions are modestly effective at reducing drinking in primary care patients with unhealthy alcohol use.

Sutfin EL; McNamara RS; Blocker JN; Ip EH; O'Brien MC; Wolfson M. Screening and brief intervention for tobacco use by student health providers on college campuses. Journal of American College Health 60(1): 66-73, 2012. (36 refs.)

Objective: This study assessed college students' reports of tobacco screening and brief intervention by student health center providers. Participants: Participants were 3,800 students from 8 universities in North Carolina. Methods: Web-based survey of a stratified random sample of undergraduates. Results: Fifty-three percent reported ever visiting their student health center. Of those, 62% reported being screened for tobacco use. Logistic regression revealed screening was higher among females and smokers, compared to nonsmokers. Among students who were screened and who reported tobacco use, 50% reported being advised to quit or reduce use. Brief intervention was more likely among current daily smokers compared to current nondaily smokers, as well as at schools with higher smoking rates. Screening and brief intervention were more likely at schools with lower clinic caseloads. Conclusions: Results highlight the need to encourage college health providers to screen every patient at every visit and to provide brief intervention for tobacco users.

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

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

Tong EK; Tang H; Chen MS; McPhee SJ. Provider smoking cessation advice among California Asian-American smokers. American Journal of Health Promotion 25(5, Supplement S): S70-S74, 2011. (9 refs.)

Purpose. To determine proportions of provider advice to quit smoking for Asian-American smokers and to describe factors that may affect the provision of such advice. Design. Secondary data analysis of population-based survey. Setting. California. Subjects. Current smokers from the California Tobacco Use Surveys for Chinese-Americans (n = 2117, participation rate = 52%), Korean-Americans (n = 2545, participation rate = 48%), and Vietnamese-Americans (n = 2179, participation rate = 63.5%). Measures. Sociodemographics including insurance status, smoking frequency, provider visit in past year, and provider advice to quit. Analysis. Multivariate logistic regression models examined dependent outcomes of (1) provider visit in past year and (2) provider advice to quit. Results. Less than a third (30.5%) of smokers in our study reported both seeing a provider (50.8%) and then receiving advice to quit (60.1%). Factors associated with provider visits included being female, being 45 years or older, having health insurance, and being Vietnamese. Among smokers who saw a provider, factors associated with provider advice to quit included having health insurance and being a daily smoker. Conclusions. Asian-American smokers reported low proportions of provider advice to quit in the past year, largely because only half of smokers saw a provider. Providers who see such smokers may need greater awareness that several effective cessation treatments do not require health insurance, and that intermittent smokers need advice to quit.

Ubina EC; Van Sell SL; Arnold C; Woods S. Best practices guidelines for nurse practitioners regarding smoking cessation in American Indian and Alaskan Native Youth. Family & Community Health 34(3): 266-274, 2011. (38 refs.)

The greatest prevalence of tobacco use in the United States occurs with the American Indian and Alaskan Native (AI/AN). A critical need exists for a culturally specific tobacco cessation option for AI/AN youth. The nurse practitioner is positioned to provide a culturally specific commercial tobacco cessation option by incorporating the transcultural nursing theory into the development of a decision tree to expand understanding of culturally appropriate best practices regarding screening and management of tobacco smoking cessation in AI/AN youth. Presented is the Nurse Practitioner Culturally Specific American Indian and Alaskan Native Youth Decision Tree for Smoking Cessation with supporting evidence-based best practices.

van Beek I; Islam MM; Topp L; Day CA; Dawson A; Conigrave KM. Maybe not perfect-but surely good enough? (editorial). International Journal of Drug Policy 23(2): 108-108, 2012. (1 refs.)

Williams JF; Ammerman SD; Levy SJL; Sims TH; Smith VC; Wunsch MJ. Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians. Pediatrics 128(5): e1330-e1340, 2011. (53 refs.)

As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatrician's confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment-matching criteria and the risk level for substance abuse.

Williams EC; Johnson ML; Lapham GT; Caldeiro RM; Chew L; Fletcher GS et al. Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review. (review). Psychology of Addictive Behaviors 25(2): 206-214, 2011. (41 refs.)

Although alcohol screening and brief intervention (SBI) reduces drinking in primary care patients with unhealthy alcohol use, incorporating SBI into clinical settings has been challenging. We systematically reviewed the literature on implementation studies of alcohol SBI using a broad conceptual model of implementation, the Consolidated Framework for Implementation Research (CFIR), to identify domains addressed by programs that achieved high rates of screening and/or brief intervention (BI). Seventeen articles from 8 implementation programs were included; studies were conducted in 9 countries and represented 533,903 patients (127,304 patients screened), 2,001 providers, and 1,805 clinics. Rates of SBI varied across articles (2-93% for screening and 0.9-73.1% for BI). Implementation programs described use of 7-25 of the 39 CFIR elements. Most programs used strategies that spanned all 5 domains of the CFIR with varying emphases on particular domains and sub-domains. Comparison of SBI rates was limited by most studies' being conducted by 2 implementation programs and by different outcome measures, scopes, and durations. However, one implementation program reported a high rate of screening relative to other programs (93%) and could be distinguished by its use of strategies that related to the Inner Setting, Outer Setting, and Process of Implementation domains of the CFIR. Future studies could assess whether focusing on Inner Setting, Outer Setting, and Process of Implementation elements of the CFIR during implementation is associated with successful implementation of alcohol screening, as well as which elements may be associated with successful, sustained implementation of BI.

Wilson GB; Lock CA; Heather N; Cassidy P; Christie MM; Kaner EF. Intervention against excessive alcohol consumption in primary health care: A survey of GPs' attitudes and practices in England 10 years on. Alcohol and Alcoholism 46(5): 570-577, 2011. (48 refs.)

Aims: To ascertain the views of general practitioners (GPs) regarding the prevention and management of alcohol-related problems in practice, together with perceived barriers and incentives for this work; to compare our findings with a comparable survey conducted 10 years earlier. Methods: In total, 282 (73%) of 419 GPs surveyed in East Midlands, UK, completed a postal questionnaire, measuring practices and attitudes, including the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Results: GPs reported lower levels of post-graduate education or training on alcohol-related issues (< 4 h for the majority) than in 1999 but not significantly so (P = 0.031). In the last year, GPs had most commonly requested more than 12 blood tests and managed 1-6 patients for alcohol. Reports of these preventive practices were significantly increased from 1999 (P < 0.001). Most felt that problem or dependent drinkers' alcohol issues could be legitimately (88%, 87%) and adequately (78%, 69%) addressed by GPs. However, they had low levels of motivation (42%, 35%), task-related self-esteem (53%, 49%) and job satisfaction (15%, 12%) for this. Busyness (63%) and lack of training (57%) or contractual incentives (48%) were key barriers. Endorsement for government policies on alcohol was very low. Conclusion: Among GPs, there still appears to be a gap between actual practice and potential for preventive work relating to alcohol problems; they report little specific training and a lack of support. Translational work on understanding the evidence-base supporting screening and brief intervention could incentivize intervention against excessive drinking and embedding it into everyday primary care practice.

Winstock AR; Mitcheson L. New recreational drugs and the primary care approach to patients who use them. (review). British Medical Journal 344: e-article e288, 2012. (34 refs.)

New drugs of misuse, including ketamine, G-hydroxybutyrate (GHB), and a range of synthetic stimulants, have become part of global recreational drug culture. Use in combination with other substances (especially alcohol) is common and increases the associated health risks. These drugs are associated with non-specific risks of intoxication and substance specific toxicological harms. Assessment and feedback using a motivational approach and provision of information about harm reduction are useful interventions that can be delivered in primary care. Referral to specialist services might be needed to manage complex withdrawal or specific harms. This clinical review addresses common examples of these new drugs, and provide a framework for conducting an interview in the primary care setting with people who may have problems with their use. Since evidence relating to these substances is inevitably limited, thus it draws upon case series, observational studies, consensus guidelines, our own clinical experiences, and those of our colleagues.

Woolhouse S; Brown JB; Thind A. 'Meeting people where they're at': Experiences of family physicians engaging women who use illicit drugs. Annals of Family Medicine 9(3): 244-249, 2011. (38 refs.)

PURPOSE: There is little research exploring the experiences of family physicians caring for women who use illicit drugs. This study explores the experiences of these physicians in order to better understand the process of engaging these women in the patient-physician relationship. METHODS: We conducted a phenomenologic, qualitative study using individual, in-depth interviews with 10 family physicians working in inner-city Toronto and Ottawa, Ontario. An iterative and interpretive analysis was used. RESULTS: Three broad themes emerged from the analysis. The predominant theme was that of the patient-physician relationship, which consisted of 2 phases: the engagement phase and the maintenance phase. During the engagement phase, issues such as access and women's experiences of trauma and violence were evident and impeded participants' ability to engage with this population. As such, the patient-physician relationship during the engagement phase was tenuous. Trust and presence were paramount during this phase. Once a family physician engaged a woman, the transition to the maintenance phase was made. Within the maintenance phase, 2 subthemes were identified: continuity of care and "meeting people where they're at" (finding common ground). CONCLUSIONS: This study identified a 2-phase process of the patient-physician relationship from the perspective of family physicians caring for women using illicit drugs: the engagement and maintenance phases. Our findings identified strategies to support the patient-physician relationship during each of these phases that have implications for improving the health of these women.

Yamada K; Hosoda M; Nakashima S; Furuta K; Awata S. Psychiatric diagnosis in the elderly referred to a consultation-liaison psychiatry service in a general geriatric hospital in Japan. Geriatrics & Gerontology International 12(2): 304-309, 2012. (23 refs.)

Aim: Because depression is a common disorder in later life, elderly patients with delirium can be misdiagnosed as having depression. This study aimed to compare psychiatric diagnoses in the elderly made by referring doctors and psychiatrists. Method: Consecutive non-psychiatric inpatients aged 65 years or older that were referred to a consultation-liaison (C-L) psychiatry service of a general hospital in Japan were enrolled. An attending psychiatrist recorded the physical and psychiatric diagnoses of the referring doctors, reason for referral, psychotropic medication and sociodemographics. The psychiatrist recorded the psychiatric diagnosis after discussion with another psychiatrist in the C-L psychiatry service. A researcher categorized the diagnoses of the referring physicians and psychiatrists as F0 (organic brain syndrome), F1 (mainly alcoholism), F2/3 (mainly depression) and F4/5 (neurosis/insomnia) using The International Classification of Mental and Behavioural Disorders, Tenth Revision (ICD-10). The degree of agreement between doctors' and psychiatrists' diagnoses was estimated for each F category using kappa statistics. Results: Of the 192 referred inpatients, 172 were enrolled (79 [ 45.9%] men; mean age 81.6 1 7.8 years). Concordance of diagnosis between doctors and psychiatrists was achieved for F0, F1, F2/3 and F4/5, resulting in kappa statistics of 0.47, 0.27, 0.28 and 0.32, respectively. The psychiatrists in this survey diagnosed 12 cases of delirium and four cases of psychoactive substance-use disorders in 23 cases of depression diagnosed by the referring doctors. Conclusion: The referring doctors in this survey had an insufficient level of diagnostic accuracy for psychiatric disorders. Delirium and psychoactive substance-use disorders were often misdiagnosed as depression.

Zwar NA; Richmond RL; Forlonge G; Hasan I. Feasibility and effectiveness of nurse-delivered smoking cessation counselling combined with nicotine replacement in Australian general practice. Drug and Alcohol Review 30(6): 583-588, 2011. (28 refs.)

Introduction and Aims. Practice nurses (PN) are an alternative workforce for cessation support in primary care, but their role and effectiveness is underdeveloped and under researched. This study evaluated a model of smoking cessation intervention in Australian general practice based on PNs. Smokers were identified by their general practitioner (GP) and referred to the PN for cessation support over four counselling visits and offered free nicotine patches. Design and Methods. Pre- and post-study using mixed quantitative and qualitative methods. Cessation outcomes were collected by patient self-report at 6 months. Semistructured interviews were conducted with PNs and GPs to provide qualitative data on the acceptability of the model. Results. The project involved 31 PNs, 35 GPs and 498 patients from 19 general practices in Sydney. Mean age of participating patients was 46 years and 61% were female. Mean number of PN counselling visits was 3.1. At 6 month follow up the point prevalence abstinence rate was 22% and continuous abstinence rate was 16%. Participants who had attended for four or more counselling visits with the PN were significantly more likely to quit. PNs and GPs expressed enthusiasm for the PN role in smoking cessation and belief in its value and feasibility. Discussion and Conclusions. Substantial rates of cessation were found in this uncontrolled study and the role was well accepted by PNs and GPs. The model shows promise as a means of providing cessation support in Australian primary care and further research in a randomised trial is warranted.