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CORK Bibliography: Primary Care

59 citations. October 2010 to present

Prepared: June 2011

Ahacic K; Allebeck P; Thakker KD. Being questioned and receiving advice about alcohol and smoking in health care: Associations with patients' characteristics, health behavior, and reported stage of change. Substance Abuse Treatment, Prevention and Policy 5: e-article 30, 2010. (43 refs.)

Background: Alcohol habits are more rarely addressed than other health behavior topics in Swedish health care. This study examined whether differences between topics could be explained by their different associations with patient characteristics or by the differences in the prevalence of the disadvantageous health behavior, i.e., excessive alcohol use and smoking. The study moreover examined whether simply being asked questions about behavior, i.e., alcohol use or smoking, was associated with reported change. Methods: The study was based on a cross-sectional postal survey (n = 4 238, response rate 56.5 percent) representative of the adult population in Stockholm County in 2003. Retrospective self-reports were used to assess health care visits during the past 12 months, the questions and advice received there, patients characteristics, health behavior, and the present stage of change. Logistic regression analysis was used to estimate the associations among the 68 percent who had visited health care. Results: Among the health care visitors, 23 percent reported being asked about their alcohol habits, and 3 percent reported receiving advice or/and support to modify their alcohol use -fewer than for smoking, physical exercise, or diet. When regression models adjusted for patient characteristics, the differences between health behaviors in the extent of questioning and advice remained. However, when the models also adjusted for smoking and alcohol consumption there was no difference between smoking and alcohol-related advice. In fact one-third of the present smokers and two-fifths of the persons dependent on alcohol reported having receiving advice the previous 12 months. Those who reported being asked questions or receiving advice more often reported a decreased alcohol use and similarly intended to cease smoking within 6 months. Questions about alcohol use were moreover related to a later stage of stage of change independently of advice among women but not among men. Conclusions: While most patients are never addressed, many in the target groups seem to be reached anyway. Besides advice, already addressing alcohol habits appears to be associated with change. The results also indicate that gender possibly plays a role in the relationship between advice and the stage of change.

Allan J. Engaging primary health care workers in drug and alcohol and mental health interventions: Challenges for service delivery in rural and remote Australia. Australian Journal of Primary Health 16(4): 311-318, 2010. (22 refs.)

Access to drug and alcohol treatment services is a particularly salient issue for Australia. The nation is paying considerable attention to risky drug and alcohol use. Indigenous Australians are particularly concerned about drug and alcohol related harms in their communities. Access to treatment is the most effective way of reducing drug related harm for disadvantaged populations. Primary health care is the optimal site for delivering drug and alcohol treatment. Semi-structured in-depth interviews with 47 primary health care, drug and alcohol and other health and welfare workers in rural and remote locations were conducted. Thematic analysis of interview data identified divergent perspectives according to a participant's work role about drug and alcohol treatment, client needs and problems and service delivery approaches. Primary health care workers were conceptualised as locals. They tended to perceive that drug and alcohol interventions should quickly prevent individuals from on-going problematic use. Drug and alcohol workers were conceptualised as insiders. Most did not have knowledge or experience of the primary health care setting. Therefore they could not assist primary health care workers to integrate drug and alcohol interventions into their interactions with clients. Professional and organisational barriers constrain the primary health care worker role and limit the application of specialist interventions. Drug and alcohol work is only one of many competing demands in the primary health setting. The lack of understanding of the primary health care worker role and responsibilities is the most significant barrier to implementing specialist interventions in this role. Primary health care workers' perceptions of substance misuse are more consistent with the individual moral or personal deficit philosophy of drug and alcohol treatment than harm minimisation approaches. This is a challenge for a specialist agency that is promoting harm minimisation and an adaptive approach to treatment within the primary care setting. Building the capacity of primary health care workers to do more varied tasks requires a good understanding of the pragmatic and practical realities of their day to day practice and the philosophies that underpin these.

Amaral-Sabadini MB; Saitz R; Souza-Formigoni MLO. Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD-related preventive care? (review). Drug and Alcohol Review 29(6): 655-661, 2010. (28 refs.)

Introduction and Aims. To explore the association between primary care professionals' (PCPs) attitudes towards unhealthy alcohol and other drug (AOD) use (from risky use through dependence) and readiness to implement AOD-related preventive care. Design and Methods. Primary care professionals from five health centres in Sao Paulo were invited to complete a questionnaire about preventive care and attitudes about people with unhealthy AOD use. Logistic regression models tested the association between professional satisfaction and readiness. Multiple Correspondence Analysis assessed associations between stigmatising attitudes and readiness. Results. Of 160 PCPs surveyed, 96 (60%) completed the questionnaire. Only 25% reported implementing unhealthy AOD use clinical prevention practices; and 53% did not feel ready to implement such practices. Greater satisfaction when working with people with AOD problems was significantly associated with readiness to implement AOD-related preventive care. In Multiple Correspondence Analysis two groups emerged: (i) PCPs ready to work with people with unhealthy AOD use, who attributed to such patients lower levels of dangerousness, blame for their condition and need for segregation from the community (suggesting less stigmatising attitudes); and (ii) PCPs not ready to work with people with unhealthy AOD use, who attributed to them higher levels of dangerousness, blame, perceived level of patient control over their condition and segregation (suggesting more stigmatising attitudes). Discussion and Conclusions. More stigmatising attitudes towards people with unhealthy AOD use are associated with less readiness to implement unhealthy AOD-related preventive care. Understanding these issues is likely essential to facilitating implementation of preventive care, such as screening and brief intervention, for unhealthy AOD use.

Anderson BL; Dang EP; Floyd RL; Sokol R; Mahoney J; Schulkin J. Knowledge, opinions, and practice patterns of obstetrician-gynecologists regarding their patients' use of alcohol. Journal of Addiction Medicine 4(2): 114-121, 2010. (26 refs.)

Objective: To evaluate the evolution of fetal alcohol spectrum disorder prevention practices including awareness and use of recently published tools. Methods: Fellows of the American College of Obstetricians and Gynecologists were asked about their knowledge, opinions, and practice regarding alcohol-related care. Eight hundred obstetrician-gynecologists (ob-gyns) were selected; 48.1% returned the survey. Results: The majority (66.0%) indicated that occasional alcohol consumption is not safe during any period of pregnancy. There was no consensus when asked if alcohol's effect on fetal development is clear (46.9% thought it was clear and 45.9% did not). Most (82.2%) ask all pregnant patients about alcohol use only during patients' initial visit, whereas 10.6% ask during initial and subsequent visits. Most (78.5%) advise abstinence when pregnant women report alcohol use. When asked which validated alcohol risk screening tool they most commonly use with pregnant patients, 57.8% said they use no tool. Although 71.9% felt prepared to screen for risky or hazardous drinking, older ob-gyns indicated feeling significantly more unprepared than younger ob-gyns. "Patient denial or resistance to treatment" was the top issue affecting alcohol screening and "referral resources for patients with alcohol problems" was the resource needed most. Most ob-gyns were not aware of the National Institute on Alcohol Abuse and Alcoholism "Clinician's Guide" or the American College of Obstetricians and Gynecologists "Fetal Alcohol Spectrum Disorder Prevention Tool Kit." Conclusions: There are few changes in the alcohol-related screening and treatment patterns of ob-gyns since 1999; although perceived barriers and needs have changed. Interventions, including referral resources and continuing medical education training, are warranted.

Anthierens S; Pasteels I; Habraken H; Steinberg P; Declercq T; Christiaens T. Barriers to nonpharmacologic treatments for stress, anxiety, and insomnia Family physicians' attitudes toward benzodiazepine prescribing. Canadian Family Physician 56(11): E398-E406, 2010. (59 refs.)

OBJECTIVE: To explore the attitudes of FPs toward benzodiazepine (BZD) prescribing and the perceived barriers to nonpharmacologic approaches to managing stress, anxiety, and insomnia. DESIGN: A questionnaire including 32 statements about treatment of insomnia, stress, and anxiety. SETTING: Local quality groups for FPs in Belgium. PARTICIPANTS: A total of 948 Belgian FPs. MAIN OUTCOME MEASURES: Barriers to using nonpharmacologic approaches in family practice. RESULTS: We identified 3 different groups of FPs according to their attitudes about BZD prescribing. A first relatively big group of FPs (39%) were not really concerned about the risks of BZD prescribing. Those in the second group (17%) were aware of the problems associated with BZDs, but did not perceive it to be their role to use nonpharmacologic approaches in family practice. Those in the third group (44%) were concerned about BZD prescribing and found it to be a "bad solution," but were faced with various barriers to applying nonpharmacologic approaches. Surprisingly, we found that nearly 97% of FPs thought that most people were eligible for nonpharmacologic approaches, but experienced implementation barriers at the level of the patient, the level of the FP, and the level of the health care system. CONCLUSION: Using different education and behavioural-change strategies for different FP groups seems important. A large group of FPs does not find prescribing BZDs to be problematic. Sensitizing and alerting FPs to this issue remains very important.

Bacha J; Reast S; Pearlstone A. Treatment practices and perceived challenges for European physicians treating opioid dependence. Heroin Addiction and Related Clinical Problems 12(3): 9-19, 2010. (44 refs.)

This survey investigated the current practices and challenges of physicians treating opioid dependence in Germany, France, Italy and the UK. Doses favoured in Europe appeared to conflict with recommended best practice, with low mean methadone and buprenorphine maintenance doses reported (44.3 and 9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer than recommended at 14.4 days. Respondents also rated diversion and misuse management as their most difficult challenge in treating opioid dependence. These data suggest that prescribing practices are likely to increase this problem, as well as impeding treatment success by decreasing compliance and retention.

Bird SM; Robertson R; Beresford H; Hutchinson SJ. Targets for Hepatitis C virus test uptake and case-finding among injecting drug users: In prisons and general practice. Addiction Research & Theory 18(4): 421-432, 2010. (20 refs.)

We re-analyse data on new diagnoses of Hepatitis C virus (HCV) for injectors in prison or attending general practices which were relied on for the cost-effectiveness of HCV testing in injectors. We use these revised estimates to suggest readily achievable targets in Scottish general practices on HCV diagnoses for injectors born in 1956-1975. Using audit data from general practices around Edinburgh, we confirm that, with effort, the suggested targets are achievable. On re-analysis, we found that over 20% of HCV-undiagnosed injectors in English prisons accepted HCV testing, and half the injectors aged 30-54 years who attended a Glasgow general practice. On the basis of 30% HCV test uptake and 80% of ever-injectors having self-identified, a target of 2500 HCV diagnoses within a year in known ever-injectors born in 1956-1975 attending Scottish general practices is feasible. Its target of five new HCV diagnoses was achieved during an HCV testing intervention by Muirhouse Practice, Edinburgh. During a 2-year audit period, 86 other general practices around Edinburgh providing enhanced services for drug users increased HCV test uptake by known ever-injectors from 43% (314/727) to 62% (655/1062) in the 1956-1975 birth-cohort. Their new HCV diagnoses in ever-injectors were 171 over two years against a target of 166 within 1 year.

Boscarino JA; Rukstalis M; Hoffman SN; Han JJ; Erlich PM; Gerhard GS et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction 105(10): 1776-1782, 2010. (52 refs.)

Aims: Our study sought to assess the prevalence of and risk factors for opioid drug dependence among out-patients on long-term opioid therapy in a large health-care system. Methods: Using electronic health records, we identified out-patients receiving 4+ physician orders for opioid therapy in the past 12 months for non-cancer pain within a large US health-care system. We completed diagnostic interviews with 705 of these patients to identify opioid use disorders and assess risk factors. Results: Preliminary analyses suggested that current opioid dependence might be as high as 26% [95% confidence interval (CI) = 22.0-29.9] among the patients studied. Logistic regressions indicated that current dependence was associated with variables often in the medical record, including age < 65 [odds ratio (OR) = 2.33, P = 0.001], opioid abuse history (OR = 3.81, P < 0.001), high dependence severity (OR = 1.85, P = 0.001), major depression (OR = 1.29, P = 0.022) and psychotropic medication use (OR = 1.73, P = 0.006). Four variables combined (age, depression, psychotropic medications and pain impairment) predicted increased risk for current dependence, compared to those without these factors (OR = 8.01, P < 0.001). Knowing that the patient also had a history of severe dependence and opioid abuse increased this risk substantially (OR = 56.36, P < 0.001). Conclusion: Opioid misuse and dependence among prescription opioid patients in the United States may be higher than expected. A small number of factors, many documented in the medical record, predicted opioid dependence among the out-patients studied. These preliminary findings should be useful in future research efforts.

Charles J; Britt H; Fahridin S. Drug abuse. Australian Family Physician 39(8): 539-539, 2010. (0 refs.)

Between April 2007 and March 2009 in the BEACH (Bettering the Evaluation and Care of Health) program, drug abuse was managed 770 times, at a rate of 0.4 per 100 encounters, suggesting it is managed by general practitioners about 436 000 times per year nationally. This article focuses on illicit drugs such as heroin and marijuana, and includes substances such as glue. Alcohol, tobacco and medicines are not included.

Cornish R; Macleod J; Strang J; Vickerman P; Hickman M. Risk of death during and after opiate substitution treatment in primary care: Prospective observational study in UK General Practice Research Database. British Medical Journal 341(c5475), 2010. (41 refs.)

Objective To investigate the effect of opiate substitution treatment at the beginning and end of treatment and according to duration of treatment. Design: Prospective cohort study. Setting UK General Practice Research Database Participants Primary care patients with a diagnosis of substance misuse prescribed methadone or buprenorphine during 1990-2005. 5577 patients with 267 003 prescriptions for opiate substitution treatment followed-up (17 732 years) until one year after the expiry of their last prescription, the date of death before this time had elapsed, or the date of transfer away from the practice. Main outcome measures: Mortality rates and rate ratios comparing periods in and out of treatment adjusted for sex, age, calendar year, and comorbidity; standardised mortality ratios comparing opiate users' mortality with general population mortality rates. Results Crude mortality rates were 0.7 per 100 person years on opiate substitution treatment and 1.3 per 100 person years off treatment; standardised mortality ratios were 5.3 (95% confidence interval 4.0 to 6.8) on treatment and 10.9 (9.0 to 13.1) off treatment. Men using opiates had approximately twice the risk of death of women (morality rate ratio 2.0, 1.4 to 2.9). In the first two weeks of opiate substitution treatment the crude mortality rate was 1.7 per 100 person years: 3.1 (1.5 to 6.6) times higher (after adjustment for sex, age group, calendar period, and comorbidity) than the rate during the rest of time on treatment. The crude mortality rate was 4.8 per 100 person years in weeks 1-2 after treatment stopped, 4.3 in weeks 3-4, and 0.95 during the rest of time off treatment: 9 (5.4 to 14.9), 8 (4.7 to 13.7), and 1.9 (1.3 to 2.8) times higher than the baseline risk of mortality during treatment. Opiate substitution treatment has a greater than 85% chance of reducing overall mortality among opiate users if the average duration approaches or exceeds 12 months. Conclusions: Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment. Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality.

Curcio F; Di Martino F; Capraro C; Angelucci F; Bulla F; Caprio N et al. Together ... to take care: Multidisciplinary management of Hepatitis C virus treatment in randomly selected drug users with chronic hepatitis. Journal of Addiction Medicine 4(4): 223-232, 2010. (21 refs.)

Hepatitis C Virus (HCV) infection is treated with peg-interferon alpha 2a or alpha 2b and ribavirin. International studies show that drug user adherence to treatment is 40% to 60% and increases if the patient is in addiction treatment. The aim of the Together To Take Care (TTTC) study was to achieve better adherence to HCV therapy in randomly selected drug users, who are considered "difficult to treat." The secondary aim of the TTTC Study Group was to standardize a method for a multidisciplinary management of the liver disease in drug users. The TTTC group data were matched with a control group. Adherence: The 93.7% of patients followed therapy prescribed; of the patients infected by HCV genotype (gt) 3, all completed therapy as scheduled. For the 48-week treatment group, 66.7% of patients completed therapy (2 of 9 patients stopped treatment for breakthrough). Toxicological results: 10 (62.5%) patients were negative in the toxicological tests (opiates, cocaine, and alcohol). Virological results: 8 of 16 patients were infected by HCV gt 1, and 8 were infected by gt 3; 2 of 16 (12.5%) patients were human immunodeficiency virus (HIV) coinfected (1 HCV gt 1a and 1 HCV gt 3). All patients: 11 of 16 (68.75%) patients were HCV ribonucleic acid undetectable 24 weeks after completing therapy (sustained virological response, SVR). Gt 1: 4 of 8 (50.0%) showed SVR. Gt 3: 7 of 8 (87.5%) showed SVR. Overall, the HCV gt 3 patients had 87.5% probability of SVR, whereas gt 1 patients had 50% probability of SVR (gt 3/gt 1 patients odds ratio = 7). The results were analyzed by Fisher exact test. Our results show that good healthcare management plays an important role in increasing patients' adherence to therapy. In the project "TTTC," the patients work with the physicians to take responsibility for their health and acquire self-efficacy and self-awareness, thanks to the special care.

Davoudi M; Rawson RA. Screening, brief intervention, and referral to treatment (SBIRT) initiatives in California: Notable trends, challenges, and recommendations. Journal of Psychoactive Drugs Supplement 6: 239-248, 2010. (41 refs.)

It is estimated that most substance users are not substance-dependent, yet they misuse alcohol and/or other drugs on a regular basis and are at risk in terms of health and further dependency. Screening, brief intervention, and referral to treatment (SBIRT) is an intervention model that identifies at-risk substance users and then provides them a patient-centered intervention. A review of selected SBIRT initiatives in California revealed a number of positive trends: the involvement of healthcare settings in substance use prevention; an increase in the number of providers trained in substance use screening; greater use of standardized screening tools; indications of reduced substance use by individuals receiving SBIRT; and the establishment of statewide policy initiatives. Despite these positive trends, SBIRT projects continue to face challenges related to leadership support, staff resources, integration into ongoing protocols, screening, client retention, client confidentiality, and data collection. To assist projects to overcome these challenges and to ensure future adoption and sustainability of SBIRT, state and local authorities can benefit from (a) promoting SBIRT among healthcare leaders, (b) identifying and sharing successful SBI RT "models," (c) providing tailored trainings and ongoing technical assistance, (d) educating providers about patient confidentiality and reimbursement laws and regulations, and (e) creating benchmark measures and data collection protocols.

Fareed A; Musselman D; Byrd-Sellers J; Vayalapalli S; Casarella J; Drexler K et al. Onsite basic health screening and brief health counseling of chronic medical conditions for veterans in methadone maintenance treatment. Journal of Addiction Medicine 4(3): 160-166, 2010. (34 refs.)

Background: To improve the delivery of health services for chronic medical conditions in our methadone clinic, we added an onsite health screening and brief health counseling to the treatment plans for patients receiving methadone maintenance treatment (MMT) at the Atlanta Veterans Affairs Medical Center. We then conducted a follow-up retrospective chart review to assess whether this intervention improved health outcome for those patients. Methods: We reviewed the charts of 102 patients who received treatment at Atlanta Veterans Affairs Medical Center methadone clinic between 2002 and 2008. We sought to determine whether our increased health education and screening intervention were associated with (1) improved drug addiction outcome (as measured by comparing percentage of opiate and cocaine positive drug screens from admission with most recent). (2) Basic health screening (as measured by the patient's compliance with primary care physician appointments and current smoking status). (3) Management of co-occurring medical conditions (as measured by levels of low-density lipoprotein cholesterol, hemoglobin A1c, and systolic blood pressure). (4) Presence of QT interval corrected (QTc) prolongation (difference in QTc between baseline and most recent electrokardiogram). Results: Illicit drug use (opiate and cocaine) markedly decreased in patients overall. The effect was more robust for those successfully "retained" (n = 55, P < 0.0001) in treatment, compared with those who "dropped out" (n = 40, P = 0.05) of treatment. Compliance with primary care physician appointments was high (82% and 88% before and after the onsite intervention, respectively) for retained patients. Low-density lipoprotein cholesterol level was within normal range for all patients. A1c improved by 40% after the onsite intervention as reflected by the decreased percentage of patients with A1c >7% from before to after the intervention (90% vs 50%, P =0.05). However, the prevalence of uncontrolled hypertension did not significantly improve after the onsite intervention (38% vs 28%, P = 0.34). As might be expected with MMT, the prevalence of QTc prolongation actually increased from 399 (+/- 92) to 439 (+/- 22) milliseconds after the onsite intervention (P = 0.003). Conclusions: Our retrospective study supports the previous literature that methadone maintenance therapy is effective in reducing illicit drug use. Although patients with history of heroin dependence and in MMT are at increased risk for chronic medical conditions, such as hepatitis C and diabetes, there are minimal federal guidelines for medical care, except than a physical examination on admission, and basic screening for some infectious diseases, eg, HIV and hepatitis C for those patients. Our study demonstrated the need for and potential benefit of enhancing the delivery of health promotion services for chronic medical conditions in methadone maintained patients. Improving management of hepatitis C, diabetes, hypertension, and other related conditions, in this high risk, difficult-to-treat, and underserved population may reduce their morbidity and premature mortality.

France K; Henley N; Payne J; D'Antoine H; Bartu A; O'Leary C et al. Health professionals addressing alcohol use with pregnant women in Western Australia: Barriers and strategies for communication. Substance Use & Misuse 45(10): 1474-1490, 2010. (32 refs.)

Health professionals have an important role to play in preventing prenatal alcohol exposure. In 2006 qualitative data were collected from 53 health professionals working in primary care in metropolitan and regional Western Australia. Thematic analysis was used to elucidate barriers in addressing prenatal alcohol use and the strategies used to overcome them. Health professionals identified strategies for obtaining alcohol use information from pregnant women but they are not recognizing moderate alcohol intake in pregnant women. Study limitations are noted and the implications of the results are discussed. This research was funded by the Health Promotion Foundation of Western Australia.

Frei M. Opioid dependence: Management in general practice. Australian Family Physician 39(8): 548-552, 2010. (21 refs.)

Background: Addiction to opioids, or opioid dependence, encompasses the biopsychosocial dysfunction seen in illicit heroin injectors, as well as aberrant behaviours in patients prescribed opioids for chronic nonmalignant pain. Objective: To outline the management of opioid dependence using opioid pharmacotherapy as part of a comprehensive chronic illness management strategy. Discussion: The same principles and skills general practitioners employ in chronic illness management underpin the care of patients with opioid dependence. Opioid pharmacotherapy, with the substitution medications methadone and buprenorphine, is an effective management of opioid dependence. Training and regulatory requirements for prescribing opioid pharmacotherapies vary between jurisdictions, but this treatment should be within the scope of most Australian GPs.

Frei M. Party drugs: Use and harm reduction26. Australian Family Physician 39(8): 558-561, 2010. (26 refs.)

Background: Party drug use, the intermittent use of stimulants, ecstasy and so-called 'designer drugs' at dance parties or 'raves', is now part of the culture of many young Australians. Objective: This article discusses the risks associated with the use of 'party drugs' and describes an useful approach to general practitioner assessment and management of patients who may be using party drugs. Discussion Party drug use is associated with a range of harms, including risks associated with behaviour while drug affected, toxicity and overdose, mental health complications and physical morbidity. Multiple substance use, particularly combining sedatives, further amplifies risk. If GPs have some understanding of these drugs and their effects, they are well placed to provide an effective intervention in party drug users by supporting the reduction of harm.

Gilchrist G; Hegarty K; Chondros P; Herrman H; Gunn J. The association between intimate partner violence, alcohol and depression in family practice. BMC Family Practice 11: e-article 72, 2010. (54 refs.)

Background: Depressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored. Methods: This paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiology Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner. Results: 23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95% CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95% CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95% CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level. Conclusions: Strategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care.

Goldman M; Suh JJ; Lynch KG; Szucs R; Ross J; Xie H et al. Identifying risk factors for marijuana use among Veterans Affairs patients. Journal of Addiction Medicine 4(1): 47-51, 2010. (42 refs.)

Objectives: Cannabis is the most widely used drug in the United States, and its use carries negative health consequences; however, universal screening for cannabis use is cumbersome. If data commonly collected in the primary care setting (eg, use of alcohol, smoking status, and depression symptoms) could predict cannabis use, then providers can implement targeted marijuana screening in high-risk groups. Methods: We reviewed Behavioral Health Laboratory data collected between 2003 and 2006 from 5512 patients referred by Veterans Affairs primary care clinics for potential mental health needs. Logistic regression was used to determine the predictors of past year marijuana use. Results: A total of 11.5% of the sample reported using marijuana in the past year. Age, gender, other drug use, presence of alcohol use disorders, smoking status, depressive disorders, posttraumatic stress disorder, anxiety disorders, and psychotic symptoms, individually, were associated with the patients' use of marijuana during the past year. When controlling for age, race, and gender in a logistic regression analyses, only other drug use, alcohol use disorder, and smoking status were linked to past year marijuana use. Patients were 5.4 (95% confidence interval [CI] 4.3-6.7) times more likely to have used marijuana during the past year if they used another illicit drug during the past year. Those with alcohol use disorder diagnosis or current smokers were 2.3 (95% CI 1.9-2.8) and 1.5 times (95% CI 1.3-1.7), respectively, more likely to have used marijuana during the past year. Receiver operating characteristic curve (area under curve = 0.79) represents good sensitivity and specificity of the model, correctly classifying 88.4% of the past year marijuana users. Conclusion: Identifying patients at high risk for cannabis use may facilitate targeted screening and provision of interventions in primary care. Patients who screen positive for cigarette use, alcohol abuse or dependence, or have evidence of other illicit drug use could be considered for cannabis screening.

Gordon AJ; Kunins HV; Rastegar DA; Tetrault JM; Walley AY. Update in addiction medicine for the generalist. Journal of General Internal Medicine 26(1): 77-82, 2011. (56 refs.)

Generalist clinicians routinely care for patients who misuse or are dependent on alcohol, nicotine, and other drugs of abuse. These problems contribute to significant morbidity, health care utilization, cost, and preventable death.The aim of this update is to identify and examine recent advances in addiction medicine that have practice implications for generalist physicians and their patients. To accomplish this, we independently selected articles in the field of addiction medicine, summarized and critically appraised, and examined the articles in the context of their implications for generalist practice using methodology we used in prior updates. During an initial review, we identified articles through an electronic MedLine search (limited to human studies and in English) using search terms for alcohol, nicotine, and other drugs of abuse from January 2008 through January 2010. From the citations, the authors selected articles for more intensive review. All authors then agreed collectively on the important articles regarding addiction medicine that have implications for practice for generalist clinicians. Topics covered in this review include prescription drug abuse, overdose deaths related to prescription drug diversion, factors influencing risk of overdose of prescribed oioids, screening in primary care, impact of intervention on health status, pharamcotherapy for smoking cessation, office-based opioid agonist therapy.

Grossberg P; Halperin A; Mackenzie S; Gisslow M; Brown D; Fleming M. Inside the physician's black bag: Critical ingredients of brief alcohol interventions. Substance Abuse 31(4): 240-250, 2010. (30 refs.)

Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians' collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.

Guassora AD; Baarts C. Smoking cessation advice in consultations with health problems not related to smoking? Relevance criteria in Danish general practice consultations. Scandinavian Journal of Primary Health Care 28(4): 221-228, 2010. (32 refs.)

Objective. To identify frames of interaction that allow smoking cessation advice in general practice consultations. Design. Qualitative study based on individual in-depth interviews with GPs and their patients. Each of the GPs' consultations were observed during a three-day period. Interviews primarily addressed the consultations that had been observed. The concept of "frames" described by Goffman was deployed as an analytic tool. Setting. Danish general practice. Subjects. Six GPs and 11 of their patients. Results. Both GPs and patients evaluated potential issues to be included during consultations by relevance criteria. Relevance criteria served the purpose of limiting the number of issues in individual consultations. Issues could be included if they connected to something already communicated in a consultation. Smoking cessation advice was subject to these relevance criteria and was primarily discussed if it posed a particular risk to a particular patient. Smoking cessation advice also occurred in conversations addressing the patient's well-being. If occurring without any other readable frame, smoking cessation advice was apt to be perceived by patients as part of a public campaign. Conclusions. Relevance criteria in the shape of communication of particular risks to particular patients and small-talk about well-being reflect the concept of "frames" by Goffman. Criteria of relevance limit the number of issues in individual consultations. Relevance criteria may explain why smoking cessation advice has not yet been implemented in many more consultations.

Heather N. Breaking new ground in the study and practice of alcohol brief interventions. Drug and Alcohol Review 29(6): 584-588, 2010. (40 refs.)

This article amplifies the decision to subtitle the INEBRIA2009 Conference 'Breaking New Ground'. The effectiveness of screening and brief intervention (SBI) for hazardous and harmful drinking is now well-established for primary health care and is promising for other medical settings. In addition, significant advances in the implementation of SBI are being made in various parts of the world. But, because of the need to establish efficacy and effectiveness, and perhaps too because of a preoccupation with meta-analysis of existing research findings, progress in other aspects of the theory and practice of SBI has been slower than ideal. There may also be a risk of complacency in the SBI field of study. For these reasons and others, the Conference Organizing Committee decided to focus the conference and invite presentations on a number of specific topics in the field of alcohol SBI and these are listed here followed by a discussion of other areas in which new ground needs to be broken.

Heather N; Kaner E. Special issue on alcohol brief interventions: Breaking new ground. Introduction. Drug and Alcohol Review 29(6): 581-583, 2010. (17 refs.)

Jenkins KR; Zucker RA. The prospective relationship between binge drinking and physician visits among older adults. Journal of Aging and Health 22(8): 1099-1113, 2010. (44 refs.)

Objectives: The objectives are to (a) determine if binge drinking is related to physician visits and (b) estimate the degree to which the relationship between binge drinking and physician visits can be explained by other health characteristics. Method: Data on a sample of 4,960 older adults (70+ years of age in 2002) from the Health and Retirement Study (HRS) were used. Three linear regression models estimated the impact of binge drinking on physician visits. Results: In the fully adjusted models, binge drinking did have an effect on the number of physician visits by older adults, with more frequent binge drinkers having fewer physician visits. This negative relationship exists even when demographic as well as other current health characteristics are controlled. Discussion: The implications of these results are discussed in terms of more broadly communicating the risks associated with binge drinking and more effectively targeting interventions to older binge drinkers.

Johansen IH; Morken T; Hunskaar S. Contacts related to mental illness and substance abuse in primary health care: A cross-sectional study comparing patients' use of daytime versus out-of-hours primary care in Norway. Scandinavian Journal of Primary Health Care 28(3): 160-165, 2010. (22 refs.)

Objective. To investigate prevalence, diagnostic patterns, and parallel use of daytime versus out-of-hours primary health care in a defined population (n = 23,607) in relation to mental illness including substance misuse. Design. Cross-sectional observational study. Setting. A Norwegian rural general practice cooperative providing out-of-hours care (i. e. casualty clinic) and regular general practitioners' daytime practices (i.e. rGP surgeries) in the same catchment area. Subjects. Patients seeking medical care during daytime and out-of-hours in 2006. Main outcome measures. Patients' diagnoses, age, gender, time of contact, and parallel use of the two services. Results. Diagnoses related to mental illness were given in 2.2% (n = 265) of encounters at the casualty clinic and in 8.9% (n = 5799) of encounters at rGP surgeries. Proportions of diagnoses related to suicidal behaviour, substance misuse, or psychosis were twice as large at the casualty clinic than at rGP surgeries. More visits to the casualty clinic occurred in months with fewer visits to rGP surgeries. Most patients with a diagnosis related to mental illness at the casualty clinic had been in contact with their rGP during the study period. Conclusion. Psychiatric illness and substance misuse have lower presentation rates at casualty clinics than at rGP surgeries. The distribution of psychiatric diagnoses differs between the services, and more serious mental illness is presented out-of-hours. The casualty clinic seems to be an important complement to other medical services for some patients with recognized mental problems.

Kaarne T; Aalto M; Kuokkanen M; Seppa K. AUDIT-C, AUDIT-3 and AUDIT-QF in screening risky drinking among Finnish occupational health-care patients. Drug and Alcohol Review 29(5): 563-567, 2010. (25 refs.)

Introduction and Aims. Primary care physicians need a brief screening instrument to detect risky drinkers. In previous studies, the three first questions of the Alcohol Use Disorders Identification Test-C (AUDIT-C) and the third question on heavy episodic drinking alone (AUDIT-3) have been shown to be almost as effective as the whole AUDIT. Also, AUDIT-QF (the first two questions of AUDIT) can be a potential screening instrument. However, the validity of these short questionnaires has not been studied among the occupational health-care patients. Design and Methods. Patients visiting their doctor in six occupational health clinics were asked to fill in a health questionnaire containing AUDIT. All together 759 patients participated in the study. Risky drinking was defined as having scored of >= 10 for men or >= 8 or more for women in the AUDIT questionnaire. Validity of AUDIT-C, AUDIT-3 and AUDIT-QF were compared against the whole AUDIT. Results. Based on the whole AUDIT, 92 (24%) of the men and 33 (9%) of the women were risky drinkers. For men and women, area under the curve was relatively high for all tested questionnaires. For AUDIT-C, the best combination of sensitivity and specificity was yielded at cut-off point of 6 for men and 4 for women. Discussion and Conclusion. Short questionnaires perform almost as well as the whole AUDIT screening risky drinking among men and women. This is why they can be recommended for clinical use in busy settings. The cut-off points, however, have to be tailored for gender and culture.

Kalapatapu RK; Paris P; Neugroschl JA. Alcohol use disorders in geriatrics. (review). International Journal of Psychiatry in Medicine 40(3): 321-337, 2010. (68 refs.)

Alcohol use disorders cause significant morbidity and mortality in the geriatric population This review article begins with a hypothetical case for illustration, asking what the primary care physician could do for a geriatric patient with alcohol abuse over a course of four office visits. Various aspects of alcohol use disorders in the geriatric population are reviewed such as range of alcohol use, epidemiology medical/psychiatric impact, detection, comprehensive treatment planning, modalities of psychotherapy, medication management, and resources for clinicians/patients.

Kann IC; Biorn E; Luras H. Competition in general practice: Prescriptions to the elderly in a list patient system. Journal of Health Economics 29(5): 751-764, 2010. (43 refs.)

Income motivation among general practitioners (GPs) is frequently discussed in the health economics literature. The question addressed in the present study on reimbursement drugs and addictive drugs is whether increased competition among GPs, which is part of a declared health policy to improve efficiency, contributes to more prescriptions for the elderly. The dataset comprises registered data of all prescribed drugs dispensed at pharmacies from the Norwegian Prescription Database merged with data on GPs. In choosing a method, particular attention is given to the fact that patients tend to be attracted to GPs who fit their preferences. Hence, we treat the composition of the patient list as endogenous. The results indicate that the stronger competition a GP faces, the more drugs are prescribed, which implies that GPs' prescription style may conflict with their role as gatekeepers, and even worse, it may be a hazard to patients' health.

Klabunde CN; Marcus PM; Silvestri GA; Han PKJ; Richards TB; Yuan GG et al. U.S. primary care physicians' lung cancer screening beliefs and recommendations. American Journal of Preventive Medicine 39(5): 411-420, 2010. (43 refs.)

Background: No high-quality study to date has shown that screening reduces lung cancer mortality, and expert groups do not recommend screening for asymptomatic individuals. Nevertheless, lung cancer screening tests are available in the U.S., and primary care physicians (PCPs) may have a role in recommending them to patients. Purpose: This study describes U.S. PCPs' beliefs about and recommendations for lung cancer screening and examines characteristics of PCPs who recommend screening. Methods: A nationally representative survey of practicing PCPs was conducted in 2006-2007. Mailed questionnaires were used to assess PCPs' beliefs about lung cancer screening guidelines and the effectiveness of screening tests and to determine whether PCPs would recommend screening for asymptomatic patients. Data were analyzed in 2009. Results: Nine hundred sixty-two PCPs completed the survey (absolute response rate = 70.6%; cooperation rate = 76.8%). One quarter said that major guidelines support lung cancer screening. Two thirds said that low-radiation dose spiral computed tomography (LDCT) screening is very or somewhat effective in reducing lung cancer mortality in current smokers; LDCT was perceived as more effective than chest x-ray or sputum cytology. Responding to vignettes describing asymptomatic patients of varying smoking exposure, 67% of PCPs recommended lung cancer screening for at least one of the vignettes. Most PCPs recommending screening said they would use chest x-ray; up to 26% would use LDCT. In adjusted analyses, PCPs' beliefs and practice style were strongly associated with their lung cancer screening recommendations. Conclusions: Many PCPs' lung cancer screening beliefs and recommendations are inconsistent with current evidence and guidelines. Provider education regarding the evidence base and guideline content of lung cancer screening is indicated.

Lewis ET; Trafton JA. Opioid use in primary care: Asking the right questions. (review). Current Pain and Headache Reports 15(2): 137-143, 2011. (55 refs.)

Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.

Liebschutz JM; Saitz R; Weiss RD; Averbuch T; Schwartz S; Meltzer EC et al. Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain. Journal of Pain 11(11): 1047-1055, 2010. (59 refs.)

This study examined characteristics associated with prescription drug use disorder (PDUD) in primary care patients with chronic pain from a cross sectional survey conducted at an urban academically affiliated safety net hospital Participants were 18 to 60 years old had pain for >= 3 months took prescription or nonprescription analgesics and spoke English Measurements included the Composite International Diagnostic Interview (PDUD other substance use disorders (SUD) Posttraumatic Stress Disorder [PTSD]) Graded Chronic Pain Scale smoking status family history of SUD and time spent in jail Of 597 patients (41% male 61% black mean age 46 years) 110 (18 4%) had PDUD of whom 99 (90%) had another SUD. In adjusted analyses those with PDUD were more likely than those without any current or past SUD to report jail time (OR 5 1 95% Cl 2 8-9 3) family history of SUD (OR 3 4 1 9 6) greater pain related limitations (OR 3 8 1 2 11 7) cigarette smoking (OR 3 6 2-6 2) or to be white (OR 3 2 1 7-6) male (OR 1 9 1 1-3 5) or have PTSD (OR 1 9 1 1-3 4) PDUD appears increased among those with easily identifiable characteristics. The challenge is to determine who among those with risk factors can avoid with proper management developing the increasingly common diagnosis of PDUD. Perspective: This article examines risk factors for prescription drug use disorder (PDUD) among a sample of primary care patients with chronic pain at an urban academic safety net hospital. The findings may help clinicians identify those most at risk for developing PDUD when developing appropriate treatment.

Lin JC; Karno MP; Barry KL; Blow FC; Davis JW; Tang LQ et al. Determinants of early reductions in drinking in older at-risk drinkers participating in the intervention arm of a trial to reduce at-risk drinking in primary care. Journal of the American Geriatrics Society 58(2): 227-233, 2010. (31 refs.)

OBJECTIVES: To describe differences between older at-risk drinkers, as determined using the Comorbidity Alcohol Risk Evaluation Tool, who reduced drinking and those who did not after an initial intervention and to determine factors associated with early reductions in drinking. DESIGN: Secondary analyses of data from a randomized controlled trial. SETTING: Seven primary care sites. PARTICIPANTS: Subjects randomized to the intervention group who completed the first health educator call approximately 2 weeks after enrollment (n = 239). INTERVENTION: Personalized risk reports, booklets on alcohol-associated risks, and advice from physicians, followed by a health educator call. MEASURMENTS: Reductions in number of alcoholic drinks. RESULTS: Thirty-nine percent of the sample had reduced drinking within 2 weeks of receiving the initial intervention. According to the final multiple logistic regression model, those who were concerned about alcohol-related risks (odds ratio (OR) = 2.03, 95% confidence interval (CI) = 1.01-4.07), read through the educational booklet (OR = 2.97, 95% CI = 1.48-5.95), or perceived that their physicians discussed risks and advised changing drinking behaviors (OR = 4.1, 95% CI = 2.02-8.32) had greater odds of reducing drinking by the first health educator call. CONCLUSION: Concern about risks, reading educational material, and perception of physicians providing advice to reduce drinking were associated with early reductions in alcohol use in older at-risk drinkers. Understanding these factors will enable development of better intervention strategies to reduce unhealthy alcohol use.

Lubetkin EI; Lu WH; Krebs P; Yeung H; Ostroff JS. Exploring primary care providers' interest in using patient navigators to assist in the delivery of tobacco cessation treatment to low income, ethnic/racial minority patients. Journal of Community Health 35(6): 618-624, 2010. (52 refs.)

We examined attitudes and practices regarding tobacco cessation interventions of primary care physicians serving low income, minority patients living in urban areas with a high smoking prevalence. We also explored barriers and facilitators to physicians providing smoking cessation counseling to determine the need for and interest in deploying a tobacco-focused patient navigator at community-based primary care practice sites. A self-administered survey was mailed to providers serving Medicaid populations in New York City's Upper Manhattan and areas of the Bronx. Provider counseling practices were measured by assessing routine delivery (a parts per thousand yen80% of the time) of a brief tobacco cessation intervention (i.e., "5 A's"). Provider attitudes were assessed by a decisional balance scale comprising 10 positive (Pros) and 10 negative (Cons) perceptions of tobacco cessation counseling. Of 254 eligible providers, 105 responded (41%). Providers estimated 22% of their patients currently use tobacco and nearly half speak Spanish. A majority of providers routinely asked about tobacco use (92%) and advised users to quit (82%), whereas fewer assisted in developing a quit plan (32%) or arranged follow-up (21%). Compared to providers reporting < 80% adherence to the "5 A's", providers reporting a parts per thousand of 80% adherence tended to have similar mean Pros and Cons scores for Ask, Advise, and Assess but higher Pros and lower Cons for Assist and Arrange. Sixty four percent of providers were interested in providing tobacco-related patient navigation services at their practices. Although most providers believe they can help patients quit smoking, they also recognize the potential benefit of having a patient navigator connect their patients with evidence-based cessation services in their community.

Lubman DI; Baker A. Cannabis and mental health: Management in primary care. Australian Family Physician 39(8): 554-557, 2010. (35 refs.)

Background: Cannabis is the most widely used illicit drug in Australia. Regular use has been associated with increased risk for a range of harms, including the development and exacerbation of mental disorders. Objective: This article reviews current evidence relating to the neuropharmacology of cannabis and its impact on mental health, as well as strategies related to the assessment and management of cannabis and co-occurring mental disorders within the primary care setting. Discussion: Early and heavy use of cannabis has been associated with the onset of psychosis and depression, while chronic use results in poorer treatment outcomes among those with co-occurring mental disorders. Effective management involves the development of therapeutic engagement and an ongoing relationship, with monitoring of cannabis use and mental health problems. Standard pharmacotherapeutic treatment of the mental disorder may be associated with a reduction in cannabis use, although adjunctive psychological intervention is also likely to be required.

Matheson C; Porteous T; van Teijlingen E; Bond C. Management of drug misuse: An 8-year follow-up survey of Scottish GPs. British Journal of General Practice 60(576): 517-520, 2010. (8 refs.)

This study repeated a Scotland-wide survey of one-in-four GPs from 2000, to compare findings with 2008. A 60% response was achieved (of 1065). Almost 44% of GPs were treating drug misusers (62% in 2000). Enhanced services were provided by less than half of practices. Seven per cent of responders were only comfortable prescribing below the recommended minimum dose of 60 mg methadone, (33% in 2000). Over 70% offered blood-borne virus screening and 71% were aware of patients using psychostimulants. Recent changes, particularly the new GP contract may have decreased GP involvement in treating drug misusers.

Meltzer EC; Rybin D; Saitz R; Samet JH; Schwartz SL; Butler SF et al. Identifying prescription opioid use disorder in primary care: Diagnostic characteristics of the Current Opioid Misuse Measure (COMM). Pain 152(2): 397-402, 2011. (31 refs.)

The Current Opioid Misuse Measure (COMM), a self-report assessment of past-month aberrant medication-related behaviors, has been validated in specialty pain management patients. The performance characteristics of the COMM were evaluated in primary care (PC) patients with chronic pain. It was hypothesized that the COMM could identify patients with prescription drug use disorder (PDD). English-speaking adults awaiting PC visits at an urban, safety-net hospital, who had chronic pain and had received any opioid analgesic prescription in the past year, were administered the COMM. The Composite International Diagnostic Interview served as the "gold standard," using DSM-IV criteria for PDD and other substance use disorders (SUDs). A receiver operating characteristic (ROC) curve demonstrated the COMM's diagnostic test characteristics. Of the 238 participants, 27 (11%) met DSM-IV PDD criteria, whereas 17 (7%) had other SUDs, and 194 (82%) had no disorder. The mean COMM score was higher in those with PDD than among all others (ie, those with other SUDs or no disorder, mean 20.4 [ SD 10.8] vs 8.4 [SD 7.5], P < .0001). A COMM score of >= 13 had a sensitivity of 77% and a specificity of 77% for identifying patients with PDD. The area under the ROC curve was 0.84. For chronic pain patients prescribed opioids, the development of PDD is an undesirable complication. Among PC patients with chronic pain-prescribed prescription opioids, the COMM is a promising tool for identifying those with PDD.

Merrick ESL; Hodgkin D; Garnick DW; Horgan CM; Panas L; Ryan M et al. Older adults' inpatient and emergency department utilization for ambulatory-care-sensitive conditions: Relationship With Alcohol Consumption. Journal of Aging and Health 23(1): 86-111, 2011. (60 refs.)

Objective: This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries. Method: This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission. Results: Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures. Discussion: Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Moore AA; Blow FC; Hoffing M; Welgreen S; Davis JW; Lin JC et al. Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial. Addiction 106(1): 111-120, 2011. (36 refs.)

Aims: To examine whether a multi-faceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months. Design: Randomized controlled trial. Setting: Three primary care sites in southern California. Participants: Six hundred and thirty-one adults aged >= 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were assigned randomly between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks. Measurements: The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (four or more drinks in a day) in the past 7 days and risk score. Findings: At 3 months, relative to controls, fewer intervention group participants were at-risk drinkers [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.22-0.75]; they reported drinking fewer drinks in the past 7 days [rate ratio (RR) 0.79; 95% CI 0.70-0.90], less heavy drinking (OR 0.46; 95% CI 0.22-0.99) and had lower risk scores (RR 0.77 95% CI 0.63-0.94). At 12 months, only the difference in number of drinks remained statistically significant (RR 0.87; 95% CI 0.76-0.99). Conclusions: A multi-faceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

Nancy Claiborne M; Videka L; Postiglione P et al. Alcohol screening, evaluation, and referral for veterans. Journal of Social Work Practice in the Addictions 10(3): 308-326, 2010. (32 refs.)

Six Veterans' Administration primary care clinics were studied for practice patterns of guidelines for alcohol problem screening and referral for further evaluation and treatment. Analysis of 31 primary care provider interviews and 650 patient electronic records revealed 75 patients (14%) scored positive on the AUDIT-C, but only 4 (5%) were referred. Electronic record prompt with practice guidelines ensured screening, but scoring was inconsistent and follow-up responsibility was diffuse. Barrier themes included (a) communication patterns within and between primary care and specialty care, (b) perceived role of behavioral health providers, and (c) provider attitudes and expectations about patients' alcohol-related behavior.

O'Connor PG; Nyquist JG; McLellan AT. Integrating addiction medicine into graduate medical education in primary care: The time has come. Annals of Internal Medicine 154(1): 56-U192, 2011. (25 refs.)

Substance use disorders create an enormous burden of medical, behavioral, and social problems and pose a major and costly public health challenge. Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care. At the center of this failure is insufficient training for physicians about substance use disorders. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed the following 5 recommendations focused on improving training in substance abuse in primary care residency programs in internal medicine and family medicine: 1) integrating substance abuse competencies into training, 2) assigning substance abuse teaching the same priority as teaching about other chronic diseases, 3) enhancing faculty development, 4) creating addiction medicine divisions or programs in academic medical centers, and 5) making substance abuse screening and management routine care in new models of primary care practice. This enhanced primary care residency training should represent a major step forward in improving patient care.

Omole OB; Ngobale KNW; Ayo-Yusuf OA. Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study. BMC Family Practice 11: e-article 94, 2010. (34 refs.)

Background: Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations. Methods: This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason (s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis. Results: Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95% CI = 2.13-9.88). Conclusion: Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

Papadakis S; McDonald P; Mullen KA; Reid R; Skulsky K; Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis. (review). Preventive Medicine 51(3-4): 199-213, 2010. (73 refs.)

Objectives. A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics. Methods. The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies. Results. Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multicomponent interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 93(95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions FOR 2.2; 95% CI 1.7-2.81 were found to significantly increase smoking abstinence. Conclusion. Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Pattison S; Heath I. On the irreducible individuality of the person and the fullness of life: Simon Gray's smoking diaries. Health Care Analysis 18(3): 310-321, 2010. (12 refs.)

This article aims to challenge and expand notions of health, health care and health promotion, particularly in relation to smoking, via a consideration of the autobiographical literary work of the English playwright, Simon Gray. Gray died in 2008, having written a series of reflective autobiographical books, The Smoking Diaries. Gray was a lifelong smoker, perpetually trying to give up his habit. This article introduces Gray's diaries and their reflections on life, death, health care and smoking. It then enquires what can be learned about contemporary health care practices and assumptions from Gray's work. Finally, it reflects on the limits of views of health and health promotion when considered in the light of a fully lived life. In the life under consideration, health care risks are very differently understood to those prevalent in the medical community. Literary approaches to thinking about smoking are thus seen to place health and health care in broader, richer, and less instrumental perspectives than those that are common amongst contemporary health professionals and institutions.

Rigotti NA. Integrating comprehensive tobacco treatment into the evolving US health care system: It's time to act. (editorial). Archives of Internal Medicine 171(1): 53-55, 2011. (21 refs.)

Rose GL; Skelly JM; Badger GJ; Maclean CD; Malgeri MP; Helzer JE et al. Automated screening for at-risk drinking in a primary care office using interactive voice response. Journal of Studies on Alcohol and Drugs 71(5): 734-738, 2010. (29 refs.)

Objective: Screening for alcohol misuse in primary care settings is strongly recommended but grossly underused. Using interactive voice response (IVR), we developed an automated screening tool (IVR Screen) for identifying alcohol misuse in outpatient primary care offices and evaluated its use rate and acceptability for both patients and providers. Method: Patients (N = 101) presenting to a primary care clinic for scheduled, nonemergent health care visits called the IVR Screen by using a dedicated telephone in the waiting room and answered five questions about their health. Results were printed immediately for patient and provider to review during the visit. Medical assistants interviewed patients about the IVR Screen in the examination room. Results: Ninety-six percent of patients who were invited to participate in the study consented to do so. Of those, 26% met criteria for alcohol misuse. Feedback from patients and providers was positive and included constructive suggestions for revisions to the IVR Screen for future use. Conclusions: IVR-based screening for at-risk drinking was feasible and did not interfere with the provider-patient interaction. The proportion of heavy drinkers identified by the IVR Screen was comparable to that of published reports of screening with written questionnaires. Implications for behavioral health screening, treatment, and clinical research are considerable because IVR-based screening assessments can be customized and targeted to different populations. Results suggest that continued development of IVR as a tool for health and alcohol screening in primary care settings is warranted.

Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking. (review). Drug and Alcohol Review 29(6): 631-640, 2010. (75 refs.)

Issues. Although screening and brief intervention (BI) in the primary-care setting reduces unhealthy alcohol use, its efficacy among patients with dependence has not been established. This systematic review sought to determine whether evidence exists for BI efficacy among patients with alcohol dependence identified by screening in primary-care settings. Approach. We included randomised controlled trials (RCTs) extracted from eight systematic reviews and electronic database searches published through September 2009. These RCTs compared outcomes among adults with unhealthy alcohol use identified by screening who received BI in a primary-care setting with those who received no intervention. Key Findings. Sixteen RCTs, including 6839 patients, met the inclusion criteria. Of these, 14 excluded some or all persons with very heavy alcohol use or dependence; one in which 35% of 175 patients had dependence found no difference in an alcohol severity score between groups; and one in which 58% of 24 female patients had dependence showed no efficacy. Conclusion and Implications. Alcohol screening and BI has efficacy in primary care for patients with unhealthy alcohol use, but there is no evidence for efficacy among those with very heavy use or dependence. As alcohol screening identifies both dependent and non-dependent unhealthy use, the absence of evidence for the efficacy of BI among primary-care patients with screening-identified alcohol dependence raises questions regarding the efficiency of screening and BI, particularly in settings where dependence is common. The finding also highlights the need to develop new approaches to help such patients, particularly if screening and BI are to be disseminated widely.

Seale JP; Shellenberger S; Clark DC. Providing competency-based family medicine residency training in substance abuse in the new millennium: A model curriculum. BMC Medical Education 10: problem ?, 2010. (87 refs.)

Background: This article, developed for the Betty Ford Institute Consensus Conference on Graduate Medical Education (December, 2008), presents a model curriculum for Family Medicine residency training in substance abuse. Methods: The authors reviewed reports of past Family Medicine curriculum development efforts, previously-identified barriers to education in high risk substance use, approaches to overcoming these barriers, and current training guidelines of the Accreditation Council for Graduate Medical Education (ACGME) and their Family Medicine Residency Review Committee. A proposed eight-module curriculum was developed, based on substance abuse competencies defined by Project MAINSTREAM and linked to core competencies defined by the ACGME. The curriculum provides basic training in high risk substance use to all residents, while also addressing current training challenges presented by U. S. work hour regulations, increasing international diversity of Family Medicine resident trainees, and emerging new primary care practice models. Results: This paper offers a core curriculum, focused on screening, brief intervention and referral to treatment, which can be adapted by residency programs to meet their individual needs. The curriculum encourages direct observation of residents to ensure that core skills are learned and trains residents with several "new skills" that will expand the basket of substance abuse services they will be equipped to provide as they enter practice. Conclusions: Broad-based implementation of a comprehensive Family Medicine residency curriculum should increase the ability of family physicians to provide basic substance abuse services in a primary care context. Such efforts should be coupled with faculty development initiatives which ensure that sufficient trained faculty are available to teach these concepts and with efforts by major Family Medicine organizations to implement and enforce residency requirements for substance abuse training.

Seigers DKL; Carey KB. Screening and brief interventions for alcohol use in college health centers: A review. (review). Journal of American College Health 59(3): 151-158, 2011. (59 refs.)

Objectives: To provide a critical review of the efficacy of brief interventions for alcohol use in college health centers. Methods: Studies were included if (a) they examined brief intervention trials that were conducted in college- or university-based student health centers or emergency departments, and (b) they provided pre-post data to estimate change. Results: Twelve studies suggested that screening and brief interventions in these settings are acceptable, feasible, and promote risk reduction. Conclusions: Findings support continued use of time-limited, single-session interventions with motivational interviewing and feedback components.

Spanou C; Simpson SA; Hood K; Edwards A; Cohen D; Rollnick S et al. Preventing disease through opportunistic, rapid engagement by primary care teams using behaviour change counselling (PRE-EMPT): Protocol for a general practice-based cluster randomised trial. BMC Family Practice 11: e-article 11, 2010. (80 refs.)

Background: Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. Methods/Design: This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Discussion: Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention. Trial Registration: ISRCTN22495456/

Squires LE; Alford DP; Bernstein J; Palfai T; Saitz R. Screening and brief intervention for drug use in primary care. (editorial). Journal of Addiction Medicine 4(3): 131-136, 2010. (23 refs.)

This clinical case involves a man with unhealthy alcohol and drug use who presents for an initial visit to primary care with complaints of heartburn and a recent admission for chest pain. Four expert clinicians contribute their thoughts about the case.

Sreeramareddy CT; Suri S; Menezes RG; Kumar HNH; Rahman M; Islam MR et al. Self-reported tobacco smoking practices among medical students and their perceptions towards training about tobacco smoking in medical curricula: A cross-sectional, questionnaire survey in Malaysia, India, Pakistan, Nepal, and Bangladesh. Substance Abuse Treatment, Prevention and Policy 5: e-article 29, 2010. (28 refs.)

Background: Tobacco smoking issues in developing countries are usually taught non-systematically as and when the topic arose. The World Health Organisation and Global Health Professional Student Survey (GHPSS) have suggested introducing a separate integrated tobacco module into medical school curricula. Our aim was to assess medical students' tobacco smoking habits, their practices towards patients' smoking habits and attitude towards teaching about smoking in medical schools. Methods: A cross-sectional questionnaire survey was carried out among final year undergraduate medical students in Malaysia, India, Nepal, Pakistan, and Bangladesh. An anonymous, self-administered questionnaire included items on demographic information, students' current practices about patients' tobacco smoking habits, their perception towards tobacco education in medical schools on a five point Likert scale. Questions about tobacco smoking habits were adapted from GHPSS questionnaire. An 'ever smoker' was defined as one who had smoked during lifetime, even if had tried a few puffs once or twice. 'Current smoker' was defined as those who had smoked tobacco product on one or more days in the preceding month of the survey. Descriptive statistics were calculated. Results: Overall response rate was 81.6% (922/1130). Median age was 22 years while 50.7% were males and 48.2% were females. The overall prevalence of 'ever smokers' and 'current smokers' was 31.7% and 13.1% respectively. A majority (> 80%) of students asked the patients about their smoking habits during clinical postings/clerkships. Only a third of them did counselling, and assessed the patients' willingness to quit. Majority of the students agreed about doctors' role in tobacco control as being role models, competence in smoking cessation methods, counseling, and the need for training about tobacco cessation in medical schools. About 50% agreed that current curriculum teaches about tobacco smoking but not systematically and should be included as a separate module. Majority of the students indicated that topics about health effects, nicotine addiction and its treatment, counselling, prevention of relapse were important or very important in training about tobacco smoking. Conclusion: Medical educators should consider revising medical curricula to improve training about tobacco smoking cessation in medical schools. Our results should be supported by surveys from other medical schools in developing countries of Asia.

Vinson DC; Manning BK; Galliber JM; Dickinson LM; Pace WD; Turner BJ. Alcohol and sleep problems in primary care patients: A report from the AAFP National Research Network. Annals of Family Medicine 8(6): 484-492, 2010. (46 refs.)

PURPOSE Hazardous and harmful drinking and sleep problems are common but their associations among patients seen in primary care have not been examined We hypothesized that greater levels of alcohol consumption would be associated with several self reported sleep problems. METHODS: In a cross sectional survey in primary care practices 94 participating clinicians recruited up to 30 consecutive adult patients and both clinicians and patients completed anonymous postvisit questionnaires. Patients were asked questions on demographics alcohol consumption cardinal symptoms of alcohol use disorders sleep quality, insomnia sleep apnea and symptoms of restless leg syndrome Multivariate analyses explored the associations of drinking status (none moderate or hazardous) and sleep problems adjusting for demographics and clustering of patients within physician. RESULTS Of 1 984 patients who responded 1 699 (85 6%) provided complete data for analysis. Respondents mean age was 50 4 years (SD 174 years) 67% were women, and 72 9% were white. Of these 22 3% reported hazardous drinking, 47 8% reported fair or poor overall sleep quality, and 7 3% reported a diagnos's or treatment of sleep apnea. Multivariate analyses showed no associations between drinking status and any measure of insomnia overall sleep quality, or restless legs syndrome symptoms Moderate drinking was associated with lower adjusted odds of sleep apnea compared with nondrinkers (OR = 0 61 95% CI 0 38 1 00) Using alcohol for sleep was strongly associated with hazardous drink ing (OR = 4 58 95% CI 2 97 708 compared with moderate drinking). CONCLUSIONS: Moderate and hazardous drinking were associated with few sleep problems. Using alcohol for sleep, however, was strongly associated with hazardous drinking relative to moderate drinking and may serve as a prompt for physicians to ask about excessive alcohol use

Wells R; Morrissey JP; Lee IH; Radford A. Trends in behavioral health care service provision by community health centers, 1998-2007. Psychiatric Services 61(8): 759-764, 2010. (26 refs.)

Objective: The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends. Methods: Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient. Results: The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9. Conclusions: The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Wilkinson SA; Miller YD; Watson B. The effects of a woman-focused, woman-held resource on preventive health behaviors during pregnancy: The Pregnancy Pocketbook. Women & Health (4): 342-358, 2010. (64 refs.)

We evaluated the effectiveness of a woman-held pregnancy record ('The Pregnancy Pocketbook') on improving health behaviors important for maternal and infant health. The Pregnancy Pocketbook was developed as a woman-focused preventive approach to pregnancy health based on antenatal management guidelines, behavior-change evidence, and formative research with the target population and health service providers. The Pregnancy Pocketbook was evaluated using a quasi-experimental, two-group design; one clinic cohort received the Pregnancy Pocketbook (n = 163); the other received Usual Care (n = 141). Smoking, fruit and vegetable intake, and physical activity were assessed at baseline (service-entry) and 12-weeks. Approximately two-thirds of women in the Pregnancy Pocketbook clinic recalled receiving the resource. A small, but significantly greater proportion of women at the Pregnancy Pocketbook site (7.6%) than the UC site (2.1%) quit smoking. No significant effect was observed of the Pregnancy Pocketbook on fruit and vegetable intake or physical activity. Few women completed sections that required health professional assistance. The Pregnancy Pocketbook produced small, but significant effects on smoking cessation, despite findings that indicate minimal interaction about the resource between health staff and the women in their care. A refocus of antenatal care toward primary prevention is required to provide essential health information and behavior change tools more consistently for improved maternal and infant health outcomes.

Williams EC; Achtmeyer CE; Kivlahan DR; Greenberg D; Merrill JO; Wickizer TM et al. Evaluation of an electronic clinical reminder to facilitate brief alcohol-counseling interventions in primary care. Journal of Studies on Alcohol and Drugs 71(5): 720-725, 2010. (30 refs.)

Objective: Brief intervention for patients with unhealthy alcohol use is a prevention priority in the United States, but most eligible patients do not receive it. This study evaluated an electronic alcohol-counseling clinical reminder at a single Veterans Affairs general medicine clinic. Method: The systems-level intervention evaluated in this study consisted of making the clinical reminder, which facilitated medical record documentation of brief intervention among patients who screened positive for unhealthy alcohol use, available to providers on one (of two) randomly selected hallways. Secondary electronic data were extracted for all patients who visited the clinic (October 1, 2002, to September 30, 2005). The proportion of patients with clinical-reminder use was evaluated among patients who screened positive for unhealthy drinking and were assigned to intervention hallway providers ("descriptive cohort"). Adjusted logistic regression evaluated the association between the intervention and resolution of unhealthy drinking at follow-up among all screen-positive patients who completed a second Alcohol Use Disorders Identification Test Consumption questionnaire 18 months or longer after the first ("outcomes cohort"). Results: Eligible patients (N = 22,863) included 10,392 controls and 12,471 in the intervention group. Fifteen percent (398 of 2,640) of descriptive cohort patients with unhealthy drinking had clinical-reminder use, which varied by severity (14% [n = 302 of 2,165] with mild/moderate and 20% [n = 96 of 475] with severe unhealthy drinking, p = .001). Only 39% (156 of 398) of patients with clinical-reminder use had documented brief intervention; advice to abstain was most common. Access to the clinical reminder was not significantly associated with resolution of unhealthy drinking in 1,358 patients in the outcomes cohort. Conclusions: Availability of a clinical reminder to facilitate brief intervention did not, alone, result in substantial use of the clinical reminder. More active implementation efforts may be needed to get brief interventions onto the agenda of busy primary care providers.

Williams EC; Peytremann-Bridevaux I; Fan VS; Bryson CL; Blough DK; Kivlahan DR et al. The association between alcohol screening scores and health status in male veterans. Journal of Addiction Medicine 4(1): 27-37, 2010. (74 refs.)

Objectives: Alcohol use is associated with self-reported health status. However, little is known about the concurrent association between alcohol screening scores and patient perception of health. We evaluated this association in a sample of primarily older male veterans. Methods: This secondary, cross-sectional analysis included male general medicine outpatients from 7 VA medical centers who returned mailed questionnaires. Screening scores from the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire were divided into 6 categories (0, 1-3, 4-5, 6-7, 8-9, and 10-12). Outcomes included scores on the 8 subscales and 2 component scores of the 36-item Short Form Health Survey (SF-36). Unadjusted and adjusted linear regression models were fit to characterize the association between AUDIT-C categories and SF-36 scores. Models were adjusted for demographic characteristics, smoking, and site-both alone and in combination with 14 self-reported comorbid conditions. Results: Male respondents (n = 24,531; mean age = 63.6 years) represented 69% of those surveyed with the SF-36. After adjustment, a quadratic (inverted U-shaped) relationship was demonstrated between AUDIT-C categories and all SF-36 scores such that patients with AUDIT-C scores 4-5 or 6-7 reported the highest health status, and patients with AUDIT-C scores 0, 8-9, and >= 10 reported the lowest health status. Conclusions: Across all measures of health status, patients with the most severe alcohol misuse had significantly poorer health status than those who screened positive for alcohol misuse at mild or moderate levels of severity. The relatively good health status reported by patients with mild-moderate alcohol misuse might interfere with clinicians' acceptance and adoption of guidelines recommending that they counsel these patients about their drinking.

Winstock AR; Ford C; Witton J. Assessment and management of cannabis use disorders in primary care. British Medical Journal 340(c1571), 2010. (29 refs.)

Cannabis use is common, especially among young people. The greatest risk of harm from cannabis use is in young people and those who are pregnant or have serious mental illness. A tenth of cannabis users develop dependence, with three quarters of them experiencing withdrawal symptoms on cessation. Most dependent users have concurrent dependence on tobacco, which increases the health risks and worsens outcomes for cannabis treatment. Brief interventions and advice on harm reduction can improve outcomes. Psychoeducation (for a better understanding of dependence), sleep hygiene, nicotine replacement therapy (where indicated), and brief symptomatic relief form the mainstay of withdrawal management. Dependent users may present with symptoms suggestive of depression, but diagnosis and treatment should be deferred until two to four weeks after withdrawal to improve diagnostic accuracy.

Zakletskaia L; Wilson E; Fleming MF. Alcohol use in students seeking primary care treatment at university health services. Journal of American College Health 59(3): 217-223, 2011. (18 refs.)

Objective: Given the high rate of at-risk drinking in college students, the authors examined drinking behaviors and associated factors in students being seen in student health services for primary care visits from October 30, 2004, to February 15, 2007. Methods: Analyses were based on a Health Screening Survey completed by 10,234 college students seeking general medical treatment. Results: Alcohol use was similar to other studies with 57% (n = 5,840) meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking. Twenty-six percent of the students reported smoking at least once in the last 3 months. Risk factors for at-risk drinking included young age, white males, drinking at a fraternity/sorority house, and use of tobacco. Conclusions: These findings support the widespread implementation of alcohol screening and intervention in university health services.

Zwar N; Richmond R; Halcomb E; Furler J; Smith J; Hermiz O et al. Quit in general practice: A cluster randomised trial of enhanced in-practice support for smoking cessation. BMC Family Practice 11: e-article 59, 2010. (45 refs.)

Background: This study will test the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by the practice nurse (PN) and tailored to meet the needs of a diversity of patients. Methods/Design: This study is a cluster randomised trial, with practices allocated to one of three groups 1) Quit with Practice Nurse 2) Quitline referral 3) GP usual care. PNs from practices randomised to the intervention group will receive a training course in smoking cessation followed by access to mentoring. GPs from practices randomised to the Quitline referral group will receive information about the study and the process of written referral and GPs in the usual care group will receive information about the study. Eligible patients are those aged 18 and over presenting to their GP who are daily or weekly smokers and who are able to give informed consent. Patients on low incomes in all three groups will be able to access free nicotine patches. Primary outcomes are sustained abstinence and point prevalence abstinence at the three month and 12 month follow-up points; and incremental cost effectiveness ratios at 12 months. Process evaluation on the reach and acceptability of the intervention approached will be collected through Computer Assisted Telephone Interviews (CATI) with patients and semi-structured interviews with PNs and GPs. The primary analysis will be by intention to treat. Cessation outcomes will be compared between the three arms at three months and 12 month follow-up using multiple logistic regression. The incremental cost effectiveness ratios will be estimated for the 12 month quit rate for the intervention groups compared to usual care and to each other. of qualitative data on process outcomes will be based on thematic analysis. Discussion: High quality evidence on effectiveness of practice nurse interventions is needed to inform health policy on development of practice nurse roles. If effective, flexible support from the PN in partnership with the GP and the Quitline could become the preferred model for providing smoking cessation advice in Australian general practice.