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CORK Bibliography: Protocols

78 citations. January 2009 to present

Prepared: September 2011

Aseltine RH; Schilling EA; James A; Glanovsky JL; Jacobs D. Age variability in the association between heavy episodic drinking and adolescent suicide attempts: Findings from a large-scale, school-based screening program. Journal of the American Academy of Child and Adolescent Psychiatry 48(3): 262-270, 2009. (77 refs.)

Objective: Alcohol use is a risk factor for suicidal behavior among adolescents, but it is not clear whether this association is consistent during the adolescent period. This study examined the age-specific associations between heavy episodic drinking (HED) and self-reported suicide attempts in a large and diverse sample of adolescents. Method: Screening data from 32,217 students, between the ages of 11 and 19 years, in 225 schools were analyzed. Logistic regression analyses estimating the impact of HIED on self-reported suicide attempts in the past year were performed. Results: Heavy episodic drinking was significantly associated with self-reported suicide attempts (odds ratio 1.78, p<.05) controlling for depressive symptoms. However, there was substantial age variability in this association, with the association between HIED and self-reported attempts stronger among younger adolescents. Among youths aged 13 years and younger, those who reported an episode of HIED during the past year were roughly 2.6 times more likely to report an attempt than those who did not report HIED in the past year, in contrast to 1.2 times among youths aged 18 years and older. Conclusions: Heavy episodic drinking is a clear risk factor for suicidal behavior among younger adolescents, beyond the risk conveyed by depressive symptoms. Further research investigating the bases for increased suicide risk among younger adolescents engaging in HED is warranted. Results provide support to AACAP's practice parameters calling for attention to substance abuse in the assessment of suicide risk and suggest that routine screening for HIED by physicians may improve the detection of adolescent suicide risk, particularly among younger adolescents.

Bader P; McDonald P; Selby P. An algorithm for tailoring pharmacotherapy for smoking cessation: Results from a Delphi panel of international experts. Tobacco Control 18(1): 34-42, 2009. (51 refs.)

Background: Evidence-based smoking cessation guidelines recommend nicotine replacement therapy (NRT), bupropion SR and varenicline as first-line therapy in combination with behavioural interventions. However, there are limited data to guide clinicians in recommending one form over another, using combinations, or matching individual smokers to particular forms. Objective: To develop decision rules for clinicians to guide differential prescribing practices and tailoring of pharmacotherapy for smoking cessation. Methods: A Delphi approach was used to build consensus among a panel of 37 international experts from various health disciplines. Through an iterative process, panellists responded to three rounds of questionnaires. Participants identified and ranked "best practices'' used by them to tailor pharmacotherapy to aid smoking cessation. An independent panel of 10 experts provided cross-validation of findings. Results: There was a 100% response rate to all three rounds. A high level of consensus was achieved in determining the most important priorities: (1) factors to consider in prescribing pharmacotherapy: evidence, patient preference, patient experience; (2) combinations based on: failed attempt with monotherapy, patients with breakthrough cravings, level of tobacco dependence; (3) specific combinations, main categories: (a) two or more forms of NRT, (b) bupropion + form of NRT; (4) specific combinations, subcategories: (1a) patch + gum, (1b) patch + inhaler, (1c) patch + lozenge; (2a) bupropion + patch, (2b) bupropion + gum; (5) impact of comorbidities on selection of pharmacotherapy: contraindications, specific pharmacotherapy useful for certain comorbidities, dual purpose medications; (6) frequency of monitoring determined by patient needs and type of pharmacotherapy. Conclusion: An algorithm and guide were developed to assist clinicians in prescribing pharmacotherapy for smoking cessation. There appears to be good justification for "off-label'' use such as higher doses of NRT or combination therapy in certain circumstances. This practical tool reflects best evidence to date of experts in tobacco cessation.

Baldus C; Miranda A; Weymann N; Reis O; More K; Thomasius R. "CAN Stop" - Implementation and evaluation of a secondary group prevention for adolescent and young adult cannabis users in various contexts study protocol. BMC Health Services Research 11: e80, 2011. (36 refs.)

Background: Current research shows that overall numbers for cannabis use among adolescents and young adults dropped in recent years. However, this trend is much less pronounced in continuous cannabis use. With regard to the heightened risk for detrimental health- and development-related outcomes, adolescents and young adults with continuous cannabis use need special attention. The health services structure for adolescents and young adults with substance related problems in Germany, is multifaceted, because different communal, medical and judicial agencies are involved. This results in a rather decentralized organizational structure of the help system. This and further system-inherent characteristics make the threshold for young cannabis users rather high. Because of this, there is a need to establish evidence-based low-threshold help options for young cannabis users, which can be easily disseminated. Therefore, a training programme for young cannabis users (age 14-21) was developed in the "CAN Stop" project. Within the project, we seek to implement and evaluate the training programme within different institutions of the help system. The evaluation is sensitive to the different help systems and their specific prerequisites. Moreover, within this study, we also test the practicability of a training provision through laypersons. Methods/Design: The CAN Stop study is a four-armed randomized wait-list controlled trial. The four arms are needed for the different help system settings, in which the CAN Stop training programme is evaluated: (a) the drug addiction aid and youth welfare system, (b) the out-patient medical system, (c) the in-patient medical system and (d) prisons for juvenile offenders. Data are collected at three points, before and after the training or a treatment as usual, and six months after the end of either intervention. Discussion: The CAN Stop study is expected to provide an evidence-based programme for young cannabis users seeking to reduce or quit their cannabis use. Moreover, we seek to gain knowledge about the programme's utility within different settings of the German help system for young cannabis users and information about the settings' specific clientele. The study protocol is discussed with regard to potential difficulties within the different settings.

Bart G. Concerns about consensus guidelines for QTc interval screening in methadone treatment. Annals of Internal Medicine 151(3): 218-218, 2009. (4 refs.)

Battersby CLF; Jermin PJ; Haigh GA; Towers TM. Clinical experience of smoking cessation advice in hospital trauma units. European Journal of Orthopaedic Surgery and Traumatology 21(6): 453-456, 2011. (18 refs.)

Cigarette smoking is increasingly well recognized as an inhibiting factor in fracture healing, and risk factor for non-union. We assessed whether adequate smoking cessation advice and support was given to cigarette smokers undergoing fracture management, based upon the United States Public Health Service 'Five As' Smoking Cessation Guidelines-evidence-based guidelines outlining effective strategy to promote smoking cessation, by taking a smoking history, advising the patient to stop smoking, assessing motivation to stop and facilitating cessation via support groups and pharmacological interventions (Ask, Advise, Assess, Assist, Arrange). Our study was conducted within three large orthopaedic units in the Mersey deanery, UK. A questionnaire was completed by 156 cigarette smokers-inpatients and outpatients-undergoing fracture management (87 M, 69 F, 18-89 years, mean age 48.2 years). All patients included within the study had been seen by an orthopaedic practitioner prior to completing the questionnaire. We assessed whether a member of the orthopaedic team had addressed each patient's smoking habits based upon the 'Five As' approach. A smoking history had been taken from 66% of smokers, 54% of those patients (36% of smokers) were advised to stop smoking. Motivation to stop smoking was assessed in only 4% of patients, whilst assistance and support relating to smoking cessation was offered to only 2.5% of patients. The assessment of smoking prevalence, and subsequent promotion of smoking cessation amongst trauma patients, is clearly suboptimal. We suggest highlighting the significance of smoking as a risk factor for impaired fracture healing amongst all healthcare professionals treating trauma patients, and the incorporation of smoking cessation advice and support into the management of orthopaedic trauma in order to promote improved fracture healing.

Batty GD; Lewars H; Emslie C; Gale CR; Hunt K. Internationally recognized guidelines for 'sensible' alcohol consumption: Is exceeding them actually detrimental to health and social circumstances? Evidence from a population-based cohort study. Journal of Public Health 31(3): 360-365, 2009. (33 refs.)

The health and social impact of drinking in excess of internationally recognized weekly (> 21 units in men; > 14 units in women) and daily (> 4 units in men; > 3 units in women) recommendations for 'sensible' alcohol intake are largely unknown. A prospective cohort study of 1551 men and women aged around 55 years in 1988 when typical alcohol consumption was recalled using a 7-day grid. An average of 3.4 years later (1990/92), study participants were re-surveyed (n = 1259; 84.7% of the target population) when they responded to nurse-administered enquiries regarding minor psychiatric morbidity, self-perceived health, hypertension, accidents, overweight/obesity and financial difficulties. Study members were followed up for mortality experience over 18 years. In fully adjusted analyses, surpassing guidelines for sensible alcohol intake was associated with an increased risk of hypertension [daily guidelines only: P-value(trend): 0.012], financial problems [weekly guidelines: P-value(difference): 0.046] and, to a lesser degree, accidents [weekly guidelines: P-value(difference): 0.065]. There was no association between either indicator of alcohol intake and mortality risk. In the present study, there was some evidence for a detrimental effect on health and social circumstances of exceeding current internationally recognized weekly and daily guidelines for alcohol intake.

Baxter S; Everson-Hock E; Messina J; Guillaume L; Burrows J; Goyder E. Factors relating to the uptake of interventions for smoking cessation among pregnant women: A systematic review and qualitative synthesis. (review). Nicotine & Tobacco Research 12(7): 685-694, 2010. (49 refs.)

The review had the aim of investigating factors enabling or discouraging the uptake of smoking cessation services by pregnant women smokers. The literature was searched for papers relating to the delivery of services to pregnant or recently pregnant women who smoke. No restrictions were placed on study design. A qualitative synthesis strategy was adopted to analyze the included papers. Analysis and synthesis of the 23 included papers suggested 10 aspects of service delivery that may have an influence on the uptake of interventions. These were whether or not the subject of smoking is broached by a health professional, the content of advice and information provided, the manner of communication, having service protocols, follow-up discussion, staff confidence in their skills, the impact of time and resource constraints, staff perceptions of ineffectiveness, differences between professionals, and obstacles to accessing interventions. The findings suggest variation in practice between services and different professional groups, in particular regarding the recommendation of quitting smoking versus cutting down but also in regard to procedural aspects, such as recording status and repeat advice giving. These differences offer the potential for a pregnant woman to receive contradicting advice. The review suggests a need for greater training in this area and the greater use of protocols, with evidence of a perception of ineffectiveness/pessimism toward intervention among some service providers.

Bell J. The global diversion of pharmaceutical drugs. Addiction 105(9): 1531-1537, 2010. (41 refs.)

Aim: To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals. Methods: The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986-2006, Australia 1996-2008 and the United States and France from the mid-1990s. Results: Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements-including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines. Conclusion: Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.

Buzina N; Goreta M; Jukic V; Peko-Covic I; Majdancic Z. Indications for psychiatric safety measures: A retrospective study. Collegium Antropologicum 33(1): 213-216, 2009. (23 refs.)

The aim of this article has been designed to investigate the influence of particular diagnostic categories on recommendations for safety measures, and to investigate the impact of constellatory factors, as the states of acute alcoholism, acute intoxication by psychoactive drugs and intense affect, on the recommendations for safety measures. The sample consisted of 120 examinees forensically expertised at the Center for Forensic Psychiatry of the Psychiatric Hospital Vrapce in the period from January 1, 1998 to December 31, 1999, and evaluated as less responsible according to the new Penal Code. All the examinees had the same legal presumptions for safety measures (decreased responsibility). The sample was divided into two groups: a group of examinees for whom a safety measure had been recommended and a group without such recommendations. The basic methodological instrument was a specially designed questionnaire with 137 items. Regarding socio-demographic characteristics, no statistically significant differences existed between the two groups taking into account age, gender, level of education and marital status. The diagnosis of personality disorder, as the first one, did not influence recommendations for safety measures. Alcohol and drug abuse were statistically significantly present in the group with recommended measures as second diagnoses, and besides influencing responsibility, had an impact on the recommendation of safety measures. An intense affect influenced the reduction of responsibility, but not the suggestion of safety measure, while alcohol and drug intoxications, besides affecting responsibility, had an impact on the suggestion of safety measure. The decisive impact of dependence influenced the recommendation for safety measures.

Byrne A. Concerns about consensus guidelines for QTc interval screening in methadone treatment. (letter). Annals of Internal Medicine 151(3): 216-216, 2009. (3 refs.)

Caplan L; Stout C; Blumenthal DS. Training physicians to do office-based smoking cessation increases adherence to PHS Guidelines. Journal of Community Health 36(2): 238-243, 2011. (23 refs.)

Cigarette smoking is the leading cause of preventable mortality and morbidity in the United States. Healthcare providers can contribute significantly to the war against tobacco use; patients advised to quit smoking by their physicians are 1.6 times more likely to quit than patients not receiving physician advice. However, most smokers do not receive this advice when visiting their physicians. The Morehouse School of Medicine Tobacco Control Research Program was undertaken to develop best practices for implementing the "2000 Public Health Services Clinical Practice Guidelines on Treating Tobacco Use and Dependence" and the "Pathways to Freedom" tobacco cessation program among African American physicians in private practice and healthcare providers at community health centers. Ten focus groups were conducted; 82 healthcare professionals participated. Six major themes were identified as barriers to the provision of smoking cessation services. An intervention was developed based on these results and tested among Georgia community-based physicians. A total of 308 charts were abstracted both pre- and post-intervention. Charts were scored using a system awarding one point for each of the five "A's" recommended by the PHS guidelines (Ask, Advise, Assess, Assist, Arrange) employed during the patient visit. The mean pre-intervention five "A's" score was 1.29 compared to 1.90 post-intervention (P < 0.001). All charts had evidence of the first "A" ("asked") both pre- and post-intervention, and the other four "A's" all had statistically significant increases pre-to post-intervention. Conclusions: The results demonstrate that, with training of physicians, compliance with the PHS tobacco guidelines can be greatly improved.

Chou R. 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain. What are the key messages for clinical practice? (review). Polish Archives of Internal Medicine 119(7-8): 469-476, 2009. (66 refs.)

Safe and effective chronic opioid therapy (COT) for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and in the assessment and management of risks associated with opioid abuse, addiction, and diversion. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on COT for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations based on the best available evidence. This article summarizes key clinical messages from this guideline regarding patient selection and risk stratification, informed consent and opioid management plans, initiation and titration of COT, use of methadone, monitoring of patients, use of opioids in high-risk patients, assessment of aberrant drug-related behaviors, dose escalations and high-dose opioid therapy, opioid rotation, indications for discontinuation of therapy, prevention and management of opioid-related adverse effects, driving and work safety, identifying a medical home and when to obtain consultation, and management of breakthrough pain.

Chou R; Fanciullo GJ; Fine PG; Adler JA; Ballantyne JC; Davies P et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. (review). Journal of Pain 10(2): 113-130, 2009. (137 refs.)

Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices. Perspective: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

Clark DB; Gordon AJ; Ettaro LR; Owens JM; Moss HB. Screening and brief intervention for underage drinkers. Mayo Clinic Proceedings 85(4): 380-391, 2010. (59 refs.)

In a 2007 report, the US Surgeeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible In general health care practice.

Cohen SP; Mao JR. Concerns about consensus guidelines for QTc interval screening in methadone treatment. (letter). Annals of Internal Medicine 151(3): 216-217, 2009. (5 refs.)

Collins SE; Eck S; Kick E; Schroter M; Torchalla I; Batra A. Implementation of a smoking cessation treatment integrity protocol: Treatment discriminability, potency and manual adherence. Addictive Behaviors 34(5): 477-480, 2009. (14 refs.)

Testing manual adherence and treatment discriminability and potency have become increasingly important to ensuring the internal validity of treatment studies [Moncher, F.J., & Prinz, RJ., (1991). Treatment fidelity in Outcome Studies. Clinical Psychology Review, 11, 247-266.]. The objective of this study was therefore to implement the treatment integrity protocol based on the standardized framework proposed by Waltz. Addis, Koerner and Jacobson [Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S., (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. journal of Consulting and Clinical Psychology, 61, 620-630.] to assess manual adherence and treatment discriminability and potency in a smoking cessation trial. Audio recordings of 15, 6-week smoking cessation groups were randomly selected from a sample of 31 groups and were rated for treatment integrity. Findings offered partial evidence for manual adherence which did not differ according to treatment condition, Analyses also indicated that the treatments were potent yet not highly discriminable across conditions. Despite some challenges, this preliminary application of the Waltz et al. [Waltz, J., Addis, M.E., Koerner, K., & Jacobson, N.S., (1993). Testing the integrity of a psychotherapy protocol: Assessment of adherence and competence. journal of Consulting and Clinical Psychology, 61, 620-630.] protocol indicated that it is a promising and flexible tool that may be used to examine different aspects of treatment integrity.

Coulton S; Perryman K; Bland M; Cassidy P; Crawford M; Deluca P et al. Screening and brief interventions for hazardous alcohol use in accident and emergency departments: A randomised controlled trial protocol. BMC Health Services Research 9(article 114), 2009. (34 refs.)

Background: There is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption on the physical, psychological and social health of the population. There also exists a substantial evidence base for the efficacy of brief interventions aimed at reducing alcohol consumption across a range of healthcare settings. Primary research conducted in emergency departments has reinforced the current evidence regarding the potential effectiveness and cost-effectiveness. Within this body of evidence there is marked variation in the intensity of brief intervention delivered, from very minimal interventions to more intensive behavioural or lifestyle counselling approaches. Further the majority of primary research has been conducted in single centre and there is little evidence of the wider issues of generalisability and implementation of brief interventions across emergency departments. Methods/design: The study design is a prospective pragmatic factorial cluster randomised controlled trial. Individual Emergency Departments (ED) (n = 9) are randomised with equal probability to a combination of screening tool (M-SASQ vs FAST vs SIPS-PAT) and an intervention (Minimal intervention vs Brief advice vs Brief lifestyle counselling). The primary hypothesis is that brief lifestyle counselling delivered by an Alcohol Health Worker (AHW) is more effective than Brief Advice or a minimal intervention delivered by ED staff. Secondary hypotheses address whether short screening instruments are more acceptable and as efficient as longer screening instruments and the cost-effectiveness of screening and brief interventions in ED. Individual participants will be followed up at 6 and 12 months after consent. The primary outcome measure is performance using a gold-standard screening test (AUDIT). Secondary outcomes include; quantity and frequency of alcohol consumed, alcohol-related problems, motivation to change, health related quality of life and service utilisation. Discussion: This paper presents a protocol for a large multi-centre pragmatic factorial cluster randomised trial to evaluate the effectiveness and cost-effectiveness of screening and brief interventions for hazardous alcohol users attending emergency departments.

Cunningham RM; Bernstein SL; Walton M; Broderick K; Vaca FE; Woolard R et al. Alcohol, tobacco, and other drugs: Future directions for screening and intervention in the emergency department. (review). Academic Emergency Medicine 16(11): 1078-1088, 2009. (129 refs.)

This article is a product of a breakout session on injury prevention from the 2009 Academic Emergency Medicine consensus conference on "Public Health in the ED: Screening, Surveillance, and Intervention." The emergency department (ED) is an important entry portal into the medical care system. Given the epidemiology of substance use among ED patients, the delivery of effective brief interventions (BIs) for alcohol, drug, and tobacco use in the ED has the potential to have a large public health impact. To date, the results of randomized controlled trials of interventional studies in the ED setting for substance use have been mixed in regard to alcohol and understudied in the area of tobacco and other drugs. As a result, there are more questions remaining than answered. The work group developed the following research recommendations that are essential for the field of screening and BI for alcohol, tobacco, and other drugs in the ED. 1) Screening-develop and validate brief and practical screening instruments for ED patients and determine the optimal method for the administration of screening instruments. 2) Key components and delivery methods for intervention-conduct research on the effectiveness of screening, brief intervention, and referral to treatment (SBIRT) in the ED on outcomes (e.g., consumption, associated risk behaviors, and medical psychosocial consequences) including minimum dose needed, key components, optimal delivery method, interventions focused on multiple risk behaviors and tailored based on assessment, and strategies for addressing polysubstance use. 3) Effectiveness among patient subgroups-conduct research to determine which patients are most likely to benefit from a BI for substance use, including research on moderators and mediators of intervention effectiveness, and examine special populations using culturally and developmentally appropriate interventions. 4) Referral strategies-a) promote prospective effectiveness trials to test best strategies to facilitate referrals and access from the ED to preventive services, community resources, and substance abuse and mental health treatment; b) examine impact of available community services; c) examine the role of stigma of referral and follow-up; and d) examine alternatives to specialized treatment referral. 5) Translation-conduct translational and cost-effectiveness research of proven efficacious interventions, with attention to fidelity, to move ED SBIRT from research to practice.

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

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

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

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

Deruvo G; Vendramin A; Di Sciascio G. Psychoactive drugs and prolongation of the QT interval. Heroin Addiction and Related Clinical Problems 11(4): 11-19, 2009. (25 refs.)

The links between psychiatry and cardiology that are pertinent to potential cardiovascular risks associated with the use of psychotropic drugs, especially antipsychotics, cannot be viewed as entirely new. In Italy, however, an important innovation was made when, on 28 February 2007, the Italian Medicines Agency (AIFA), issued a directive laying down provisions for the amendment of the printed papers that accompany various medicines, including haloperidol: that initiative has revived the relevance of the whole question. In particular, contraindications to the use of these drugs have been redefined. The primary ones are now listed as acute myocardial infarction, decompensated heart failure, arrhythmias treated with antiarrhythmic drugs be longing to special classes, the prolongation of the QT interval corrected for heart rate (QTc), the family history for arrhythmia or torsades de pointes, hypokalaemia and the concomitant use of drugs that prolong the QTc.

Dom G; Francque S; Michielsen P. Risk for relapse of alcohol use after liver transplantation for alcoholic liver disease: A review and proposal of a set of risk assessment criteria. (review)18. Acta Gastro-Enterologica Belgica Acta Gastro-Enterologica Belgica(2): 247-251, 2010. (18 refs.)

Background : Liver transplantation for end stage alcoholic liver disease is becoming an increasingly frequent procedure. Within this context assessing the risk on relapse in alcohol use is a major issue. However, up to now, there is a clear lack in validated criteria that can be used to assess future relapse risk. Method : Literature review based upon Medline search identifying all new studies that have been published after the latest meta-analysis on this subject (2007-2009). Results : Five new original studies were identified. They provide new evidence for the prospective validity of different criteria; pre-transplant abstinence duration, diagnosis of alcohol dependence versus abuse, level of social support, additional psychiatric co-morbidity. Conclusions: These criteria seem promising as to the prediction of relapse in alcohol after liver transplantation. Based upon these results a new comprehensive assessment scale is proposed.

Doran D; Paterson J; Clark C; Srivastava R; Goering PN; Kushniruk AW et al. A pilot study of an electronic interprofessional evidence-based care planning tool for clients with mental health problems and addictions. Worldviews on Evidence-Based Nursing 7(3): 174-184, 2010. (14 refs.)

Background: The health system must develop effective solutions to the growing challenges it faces with respect to individuals who suffer with mental health disorders and addictions. The purpose of this study was to evaluate the usability and potential impact on outcomes of a knowledge translation system aimed at improving client-centered, evidence-based care for hospitalized individuals with schizophrenia. Methodology: A pre-posttest design was used. The e-Volution-TREAT system was implemented on two inpatient units at a large mental health facility. Thirty-seven nurses, allied health workers, and physicians participated from two units. Data collection involved questionnaires, semistructured interviews, and observations. Thirty-eight consenting clients' outcome data were collected from organizational records. Results: Overall, staff participants were very satisfied with the functions of the e-Volution-TREAT system. Barriers to using the system were identified by participants related to the work environment, to understaffing, equipment problems, discomfort with technology, and a focus on short-term rather than long-term goals. There was moderate uptake of guidelines related to social issues, and low uptake of guidelines related to family support and addictions. There were significant improvements in four client outcomes over time, specifically aggressive behavior, depression, withdrawal, and psychosis. Conclusions: In conclusion, users were overall satisfied with the e-Volution-TREAT system, although expressed challenges related to workload that interfered with time to utilize the system. It would be premature to conclude the change in client outcomes was related to the e-Volution-TREAT system without a randomized controlled trial with outcomes compared to a control group. Future research needs to incorporate strategies for modifying the context and engage clinicians who are in a position of influence to model change.

El-Guebaly N; Sareen J; Stein MB. Are there guidelines for the responsible prescription of benzodiazepines? (editorial). Canadian Journal of Psychiatry 55(11): 709-714, 2010. (27 refs.)

Fishbain DA; Lewis JE; Gao JR. Medical malpractice allegations of iatrogenic addiction in chronic opioid analgesic therapy: Forensic case reports. (editorial). Pain Medicine 11(10): 1537-1545, 2010. (41 refs.)

Objectives. The objectives for presenting these medico-legal forensic case reports are the following: 1) detail three cases where chronic opioid analgesic therapy (COAT) was alleged to cause iatrogenic addiction and/or re-addiction; 2) detail the plaintiff's and defendant's medical experts' opinions on these allegations; and 3) through analyzing these cases, develop some recommendations for future prevention of such allegations during COAT. Methods. Case Reports. Results. Medico-legal issues surrounding the allegation of iatrogenic addiction were identified in each case. Conclusions. Before starting COAT, physicians should obtain and document patient informed consent for the risk of addiction/re-addiction with COAT treatment. Patients with a history of addictions pre-COAT should be placed on adherence monitoring immediately on beginning COAT.

Flenady V; Macphail J; New K; Devenish-Meares P; Smith J. Implementation of a clinical practice guideline for smoking cessation in a public antenatal care setting. Australian & New Zealand Journal of Obstetrics & Gynaecology 48(6): 552-558, 2009. (25 refs.)

Despite high level evidence showing that antenatal smoking cessation programs are effective in reducing the number of women who smoke during pregnancy and the number of low birthweight and preterm births, few Australian hospitals have adopted a systematic approach to assist pregnant women to stop smoking. The aim of this study was to assess the effectiveness of a smoking cessation guideline, developed specifically for clinicians providing antenatal care in public maternity hospitals, combined with an implementation program on the uptake of evidence-based practice. A clinical practice guideline was developed and an implementation strategy was tested, using a prospective before-and-after study design, at the Mater Mothers' Hospital in Brisbane. Women were surveyed in late pregnancy, pre- and post-implementation. The primary outcome measures were women's report of appropriate smoking cessation support received, specifically, information brochures and referral to Quitline. Secondary outcome measures included women's report of smoking status in late pregnancy and relapse rates. Post-implementation, more women reported receiving written materials on smoking cessation (76% vs 35%; relative risk (RR) 3.4; 95% confidence interval (CI) 2.7, 4.2) and referral to Quitline (67% vs 14%; RR 4.9; 95% CI 3.0, 8.0). While not statistically significant, fewer women post-implementation reported smoking in late pregnancy (19.5% vs 16.7%) and fewer reported smoking > 10 cigarettes per day (38% vs 25%). Clinical practice guidelines specifically designed for a public maternity care setting combined with an implementation program resulted in an increase in evidence-based practice with some indication of improved smoking behaviour for women.

Gan QA; Lu W; Xu JY; Li XJ; Goniewicz M; Benowitz NL et al. Chinese 'low-tar' cigarettes do not deliver lower levels of nicotine and carcinogens. Tobacco Control 19(5): 374-379, 2010. (20 refs.)

Background Low tar cigarette smoking is gaining popularity in China. The China National Tobacco Corporation (CNTC) promotes low tar cigarettes as safer than regular cigarettes. Methods: A total of 543 male smokers smoking cigarettes with different tar yields (15 mg regular cigarettes 10-13 mg low tar cigarettes and <10 mg low tar cigarettes) were recruited in Shanghai China who then completed a questionnaire on smoking behaviour and provided a urine sample for analysis of the nicotine metabolites cotinine and trans 3 hydroxycotinine. A total of 177 urine samples were selected at random for the analysis of the carcinogens polycyclic aromatic hydrocarbon metabolites (PAHs) (1 hydroxypyrene naphthols hydroxyfluorenes and hydroxyphenanthrenes) and the tobacco specific nitrosamine 4 (methylnitrosamino) 1 (3 pyridyl) butanone (NNK) metabolites 4 (methylnitrosamino) 1 (3 pyridyl) butanol (NNAL) and NNAL glucuronide .Values were normalised by creatinine to correct for possible distortions introduced by dilution or concentration of the urine. Results: Smokers of low tar cigarettes smoked fewer cigarettes per day (p=0 001) compared to smokers of regular cigarettes. Despite this lower reported consumption levels of cotinine trans 3 hydroxycotinine and PAHs in urine of people smoking low tar cigarettes were not correlated with nominal tar delivery of the cigarettes they smoked. Urine concentrations of NNAL were higher in smokers of lower tar than higher tar cigarettes. Conclusions: Chinese low tar cigarettes do not deliver lower doses of nicotine and carcinogens than regular cigarettes therefore it is unlikely that there would be any reduction in harm CNTC s promotion of low tar cigarettes as less harmful is a violation of the World Health Organization Framework Convention on Tobacco Control which China ratified in 2005

Gifford AE; Farkas KJ; Jackson LW; Molteno CD; Jacobson JL; Jacobson SW et al. Assessment of benefits of a universal screen for maternal alcohol use during pregnancy. Birth Defects Research. Part A: Clinical and Molecular Teratology 88(10, special issue): 838-846, 2010. (40 refs.)

INTRODUCTION: The objective of this report is to estimate the benefits of universal meconium screening for maternal drinking during pregnancy. Fetal alcohol spectrum disorder (FASD), including its most severe manifestation fetal alcohol syndrome (FAS), is preventable and remains a public health tragedy. The incidences of FAS and FASD have been conservatively estimated to be 0.97 and 10 per 1000 births, respectively. Meconium testing has been demonstrated to be a promising at-birth method for detection of drinking during pregnancy. METHODS: The current costs of FAS and FASD, alcohol treatment programs, and meconium screening were estimated by literature review. Monetary values were converted roughly to equal dollars in 2006. RESULTS: Costs of adding meconium analysis to the current newborn screening program and of treatment for the identified mothers were estimated and compared to potential averted costs that may result from identification and intervention for mothers and affected infants. Three potential maternal treatment strategies are analyzed. Depending on the treatment type, the savings may range from $6 to $97 for every $1 spent on screening and treatment. DISCUSSION: It needs to be emphasized, however, that such screening is premature and that to be effective this screening can be implemented only if there is a societal willingness to institute prevention and intervention programs to improve both women's and children's health. Future research should be directed at improving detection and developing in-depth prevention and remedial intervention programs. A thorough consideration of the ethical issues involved in such a screening program is also needed.

Girgis G. Concerns about consensus guidelines for QTc interval screening in methadone treatment. (letter). Annals of Internal Medicine 151(3): 217-218, 2009. (9 refs.)

Glass JE; Perron BE; Ilgen MA; Chermack ST; Ratliff S; Zivin K. Prevalence and correlates of specialty substance use disorder treatment for Department of Veterans Affairs Healthcare System patients with high alcohol consumption. Drug and Alcohol Dependence 112(1-2): 150-155, 2010. (31 refs.)

Objective: Current substance use disorder (SUD) treatment guidelines suggest that SUD treatment may be indicated for individuals with elevated levels of alcohol consumption. The Department of Veterans Affairs (VA) considers patients with AUDIT-C scores of >= 8 as candidates for specialty care, however rates of SUD treatment based on AUDIT-C cutoffs remain understudied. We sought to identify SUD treatment rates and to identify patient characteristics that were associated with SUD treatment for VA patients with elevated AUDIT-C scores. Methods: The study sample included 10,384 ambulatory care VA patients with AUDIT-C scores of >= 8, who had not received SUD treatment in the past 60 days. Data were ascertained from the 2005 Survey of Health Experiences of Patients, a confidential mailed patient satisfaction survey (results were not available to providers). The outcome variable was the receipt of VA specialty SUD treatment in the year after the survey completion, as ascertained by VA administrative data. We identified rates of SUD treatment, and conducted unadjusted F tests and adjusted logistic regression analyses to identify patient characteristics that were associated with treatment entry. Results: Approximately 3.9% of veterans with AUDIT-C scores of >= 8 received SUD treatment in the year after being surveyed. Adjusted analyses revealed that treatment was more likely among persons with a mental health diagnosis (OR = 3.31, CI = 2.30-4.76) and among racial/ethnic minority groups. Conclusions: Very few veterans who reported elevated alcohol consumption on SHEP received specialty SUD treatment in the year after being surveyed. Increased efforts should be made to intervene with patients who have elevated levels of alcohol consumption.

Glynn TJ. Commentary on Bitton, et al. (2010): 'Yes, but will it work?'-the need for a formal evaluation process for the Framework Convention on Tobacco Control. (commentary). Addiction 105(12): 2192-2194, 2010. (6 refs.)

Green SM; Roback MG; Kennedy RM; Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. (review). Annals of Emergency Medicine 57(5): 449- 461, 2011. (112 refs.)

We update an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department procedural sedation and analgesia. Substantial new research warrants revision of the widely disseminated 2004 guideline, particularly with respect to contraindications, age recommendations, potential neurotoxicity, and the role of coadministered anticholinergics and benzodiazepines. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for ketamine dissociative sedation.

Guo FR; Hung LY; Chang CJ; Leung KK; Chen CY. The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline. BMC Public Health 10: 77, 2010. (32 refs.)

Background: The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short-and long term efficacy of the training program. Methods: For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires. Results: Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence. Conclusions: The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.

Hays JT; Ebbert JO; Sood A. Treating tobacco dependence in light of the 2008 US Department of Health and Human Services Clinical Practice Guideline. (review). Mayo Clinic Proceedings 84(8): 730-735, 2009. (28 refs.)

Cigarette smoking Is the most Important preventable cause of morbidity, mortality, and excess health care costs In the United States. From 2000 through 2004, cigarette smoking caused an estimated annual average of 443,595 deaths and cost $193 billion per year In smoking-attributable productivity losses and smoking-related health care expenditures. Preventing smoking and providing effective treatment to help smokers quit will remain a public health priority for the. foreseeable future. In support of this goal, the US Department of Health and Human Services recently published the clinical practice guideline entitled Treating Tobacco Use and Dependence: 2008 Update. The new guideline updates the previous guidelines published In 1996 and 2000 and presents many new research findings to provide a broader evidence base for effective Intervention. This article briefly reviews the major updates and recommendations from the new guideline and highlights Its practical clinical applications.

Heil SH; Scott TL; Higgins ST. An overview of principles of effective treatment of substance use disorders and their potential application to pregnant cigarette smokers. Drug and Alcohol Dependence 104(Supplement 1): S106-S114, 2009. (92 refs.)

Cigarette smoking remains a leading preventable cause of poor pregnancy outcomes and infant morbidity and mortality. Despite three decades of research encompassing more than 60 trials and 20,000 pregnant women, cessation rates produced by existing interventions are often low (<20%), especially among socioeconomically disadvantaged women. This has led to a call for the development and testing of novel interventions. One strategy for identifying novel interventions for pregnant smokers is to examine efficacious interventions for other types of substance use disorders (SUDs). Pregnant smokers share many sociodemographic similarities with other sub-populations of individuals with SUDs, suggesting that interventions efficacious with the latter may also benefit the former. The National Institute on Drug Abuse's guide, "Principles of Drug Addiction Treatment: A Research-based Guide", presents empirically validated principles of effective treatments for other SUDs. The present report enumerates these principles, briefly describes some of the empirical evidence supporting them, and explores their potential application to the treatment of smoking during pregnancy. Overall, the results of this exercise suggest much promise for enhancing treatment outcomes for pregnant smokers by borrowing from and extending what has been learned with other populations with SUDs.

Hughes JR. Ethical concerns about non-active conditions in smoking cessation trials and methods to decrease such concerns. (review). Drug and Alcohol Dependence 100(3): 187-193, 2009. (53 refs.)

Many have questioned whether it is ethical to assign participants in a research trial to a non-active control condition (e.g., a placebo or attention-only control) when (a) the disorder under Study is serious, (b) validated treatment is available, and (c) harm may occur if treatment is not given. This ethical concern May apply to Studies of controlled trials of treatments for drug dependence. The current paper examines this concern for trials of nicotine dependence because there are multiple validated treatments available. The major harm from assignment to a non-active condition in such a trial could occur if failure to quit discourages smokers from trying to quit again. Whether this harm actually Occurs is unclear. Potential harms from non-active conditions may be mitigated by (a) provision of more explicit information in the consent process, (b) inclusion of only those who have failed optimal treatment, (c) provision of validated treatment via a different Modality, (d) tests of the new treatment as an add-on to standard treatment, (e) use of dose-response design, (f) use of unequal randomization designs, (g) use of stopping rules, (h) provision of optimal therapy to those who fail during the study, or (i) comparison of the experimental treatment vs. standard treatment. Empirical research to inform ethical analysis of non-active conditions in drug abuse research is suggested.

John-Baptiste A; Varenbut M; Lingley M; Nedd-Roderique T; Teplin D; Tomlinson G et al. Treatment of hepatitis C infection for current or former substance abusers in a community setting. Journal of Viral Hepatitis 16(8): 557-567, 2009. (43 refs.)

Substance abusers account for the largest number of hepatitis C infected cases in developed countries. We describe a care model for treating current or former substance abusers with antiviral therapy for hepatitis C virus (HCV) infection. The care model involved hepatitis nurses, a psychologist, infectious disease specialist and primary care physicians. Clients met selection criteria including regular attendance at clinic appointments and social stability. Use of alcohol and illicit substances was monitored with urine toxicology screens. The association between substance use, rates of completion of therapy and rates of response were assessed using multivariable regression analyses. A total of 109 clients (75 with genotype 1/4 and 34 with genotype 2/3) received at least one injection with pegylated interferon between November 2002 and January 2006. Treatment completion rates of 61 and 74% were achieved for genotypes 1/4 and 2/3, respectively. Treatment response rates in an intention to treat analysis were 51% for genotypes 1/4 and 68% for genotypes 2/3. A positive urine toxicology screen indicating use of illicit substances 6 months prior to initiating therapy was significantly associated with lower rates of treatment completion but not lower rates of sustained virological response. A positive urine screen indicating use of alcohol prior to therapy was significantly associated with lower rates of completion and lower rates of response. Rates of completion and response are comparable to non-substance abusing populations. Antiviral therapy for HCV infection can be successful within the context of ongoing care for substance abuse for carefully selected patients.

Kaner E. NICE work if you can get it: Development of national guidance incorporating screening and brief intervention to prevent hazardous and harmful drinking in England. Drug and Alcohol Review 29(6): 589-595, 2010. (54 refs.)

This paper describes the development of the first set of national guidance focused on the prevention of alcohol problems in England. These guidelines were produced by the National Institute for Health and Clinical Excellence (NICE) working with a multidisciplinary program development group of scientists, practitioners and lay members. In this work, screening and brief alcohol interventions represent a key element of a comprehensive public health strategy to prevent alcohol-related risk and harm across the population. The first controlled trials of brief alcohol intervention were published in the mid to late 1980's and there are now around 60 published trials in this field. After 25 years of accumulated evidence in this field, brief alcohol interventions have yet to make a significant impact on routine clinical practice. While it is imperative to have good science to make the case for brief intervention delivery, this work is in vain if practitioners are unwilling or unable to use these interventions with their patients. Evidence from the alcohol field and other clinical areas indicates that national prioritisation of brief alcohol intervention activity, by a body, such as NICE, is likely to be a key driver of implementation by practitioners. This paper summarises a suite of complementary system-level and practice recommendations, which were published by NICE in June 2010, and considers their likely impact on screening and brief alcohol in England.

Kaner E; Bland M; Cassidy P; Coulton S; Deluca P; Drummond C et al. Screening and brief interventions for hazardous and harmful alcohol use in primary care: A cluster randomised controlled trial protocol. BMC Public Health 9(article 287), 2009. (47 refs.)

Background: There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients. Methods and design: GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial. Discussion: The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.

King B; Borland R; Abdul-Salaam S; Polzin G; Ashley D; Watson C; O'Connor RJ. Divergence between strength indicators in packaging and cigarette engineering: A case study of Marlboro varieties in Australia and the USA. Tobacco Control 19(5): 398-402, 2010. (27 refs.)

Objectives: To investigate how the tobacco industry is adapting to regulatory action in accordance with provisions of the Framework Convention on Tobacco Control that targets misleading packaging and labelling. To relate the packaging and labelling of new cigarette varieties to their construction and performance. Methods: The principal design features and tar nicotine and carbon monoxide yields of the Marlboro brand family in Australia were measured and compared with those of the US equivalents. Results: Marlboro Red and Blue/Medium could not be differentiated in preliminary tests in Australia but were different in the USA. However, yield testing showed Marlboro Blue/Medium did not have lower tar and nicotine yields in either country indeed being higher in Australia. Conclusions: Colour can be used to market cigarettes as milder independently of ISO yields and Light/Mild descriptors. Banning of Light and Mild brand descriptors may be inadequate to end belief in less harmful cigarettes so long as the tobacco industry remains free to engineer mildness and to use colours other descriptors and design features to characterise varieties it wants to market as milder

Kingston AH; Jorm AF; Kitchener BA; Hides L; Kelly CM; Morgan AJ et al. Helping someone with problem drinking: Mental health first aid guidelines: A Delphi expert consensus study. BMC Psychiatry 9(79), 2009. (27 refs.)

Background: Alcohol is a leading risk factor for avoidable disease burden. Research suggests that a drinker's social network can play an integral role in addressing hazardous (i.e., high-risk) or problem drinking. Often however, social networks do not have adequate mental health literacy (i.e., knowledge about mental health problems, like problem drinking, or how to treat them). This is a concern as the response that a drinker receives from their social network can have a substantial impact on their willingness to seek help. This paper describes the development of mental health first aid guidelines that inform community members on how to help someone who may have, or may be developing, a drinking problem (i.e., alcohol abuse or dependence). Methods: A systematic review of the research and lay literature was conducted to develop a 285-item survey containing strategies on how to help someone who may have, or may be developing, a drinking problem. Two panels of experts (consumers/carers and clinicians) individually rated survey items, using a Delphi process. Surveys were completed online or via postal mail. Participants were 99 consumers, carers and clinicians with experience or expertise in problem drinking from Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States. Items that reached consensus on importance were retained and written into guidelines. Results: The overall response rate across all three rounds was 68.7% (67.6% consumers/carers, 69.2% clinicians), with 184 first aid strategies rated as essential or important by >= 80% of panel members. The endorsed guidelines provide guidance on how to: recognize problem drinking; approach someone if there is concern about their drinking; support the person to change their drinking; respond if they are unwilling to change their drinking; facilitate professional help seeking and respond if professional help is refused; and manage an alcohol-related medical emergency. Conclusion: The guidelines provide a consensus-based resource for community members seeking to help someone with a drinking problem. Improving community awareness and understanding of how to identify and support someone with a drinking problem may lead to earlier recognition of problem drinking and greater facilitation of professional help seeking.

Kingston AH; Morgan AJ; Jorm AF; Hall K; Hart LM; Kelly CM. Helping someone with problem drug use: A delphi consensus study of consumers, carers, and clinicians. BMC Psychiatry 11: e-article 3, 2011. (20 refs.)

Background: Problem use of illicit drugs (i.e. drug abuse or dependence) is associated with considerable health and social harms, highlighting the need for early intervention and engagement with health services. Family members, friends and colleagues play an important role in supporting and assisting individuals with problem drug use to seek professional help, however there are conflicting views about how and when such support should be offered. This paper reports on the development of mental health first aid guidelines for problem drug use in adults, to help inform community members on how to assist someone developing problem drug use or experiencing a drug-related crisis. Methods: A systematic review of the scientific and lay literature was conducted to develop a 228-item survey containing potential first-aid strategies to help someone developing a drug problem or experiencing a drug-related crisis. Three panels of experts (29 consumers, 31 carers and 27 clinicians) were recruited from Australia, Canada, New Zealand, the United Kingdom, and the United States. Panel members independently rated the items over three rounds, with strategies reaching consensus on importance written into the guidelines. Results: The overall response rate across three rounds was 80% (86% consumers, 81% carers, 74% clinicians). 140 first aid strategies were endorsed as essential or important by 80% or more of panel members. The endorsed strategies provide information and advice on what is problem drug use and its consequences, how to approach a person about their problem drug use, tips for effective communication, what to do if the person is unwilling to change their drug use, what to do if the person does (or does not) want professional help, what are drug-affected states and how to deal with them, how to deal with adverse reactions leading to a medical emergency, and what to do if the person is aggressive. Conclusions: The guidelines provide a consensus-based resource for community members who want to help someone with a drug problem. It is hoped that the guidelines will lead to better support and understanding for those with problem drug use and facilitate engagement with professional help.

Krantz MJ; Martin J; Stimmel B; Haigney MCP. Concerns about consensus guidelines for QTc interval screening in methadone treatment response. (letter, response). Annals of Internal Medicine 151(3): 218-219, 2009. (7 refs.)

Krebs EE; Ramsey DC; Miloshoff JM; Bair MJ. Primary care monitoring of long-term opioid therapy among veterans with chronic pain. Pain Medicine 12(5): 740- 746, 2011. (27 refs.)

Objective. To characterize long-term opioid prescribing and monitoring practices in primary care. Design:. Retrospective medical record review. Setting. Primary care clinics associated with a large Veterans Affairs (VA) medical center. Patients. Adult patients who filled >= 6 prescriptions for opioid medications from the outpatient VA pharmacy between May 1, 2006 and April 30, 2007. Outcome Measures. Indicators of potential opioid misuse, documentation of guideline-recommended opioid-monitoring processes. Results. Ninety-six patients (57%) received a long-acting opioid, 122 (72%) received a short-acting opioid, and 50 (30%) received two different opioids. Indicators of some form of potential opioid misuse were present in the medical records of 55 (33%) patients. Of the seven guideline-recommended opioid-monitoring practices we examined, the mean number documented within 6 months was 1.7 (standard deviation [SD] 1.5). Pain reassessment was the most frequently documented process (N = 105, 52%), and use of an opioid treatment agreement was the least frequent (N = 19, 11%). Patients with indicators of potential opioid misuse had more documented opioid-monitoring processes than those without potential misuse indicators (2.4 vs 1.3, P < 0.001). After adjustment, potential opioid misuse was positively associated with the number of documented guideline-recommended processes (mean = 1.0 additional process, 95% confidence interval [CI] 0.4, 1.5). Conclusions. Guideline-recommended opioid management practices were infrequently documented overall but were documented more often for higher risk patients who had indicators of potential opioid misuse. The relationship between guideline-concordant opioid management and high-quality care has not been established, so our findings should not be interpreted as evidence of poor quality opioid management. Research is needed to determine optimal methods of monitoring opioid therapy in primary care.

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.

Lo CF. FCTC guidelines on tobacco industry foreign investment would strengthen controls on tobacco supply and close loopholes in the tobacco treaty. Tobacco Control 19(4): 306-310, 2010. (18 refs.)

The Framework Convention on Tobacco Control (FCTC) contains no provisions covering tobacco industry investments. This creates the potential for tobacco companies to benefit from investment liberalisation by using foreign investments to avoid tobacco tariffs, increase tobacco consumption and otherwise impair the implementation of FCTC-style measures. Reducing and ultimately eliminating foreign investment activities by tobacco companies can be justified on health grounds, even though it runs counter to current investment liberalisation trends. Through the FCTC process, nonbinding guidelines can be elaborated to assist parties in recognising and responding to foreign investment strategies of tobacco companies, to support efforts to exclude the tobacco sector from investment liberalisation and otherwise would improve all countries' awareness of the threat from foreign investment strategies of tobacco companies and provide them with approaches to handle the problems.

Lv J; Su M; Hong ZH; Zhang T; Huang XM; Wang B et al. Implementation of the WHO Framework Convention on Tobacco Control in mainland China. Tobacco Control 20(4): 309-314, 2011. (56 refs.)

As per China's ratification of the WHO Framework Convention on Tobacco Control (FCTC), it should have implemented effective packaging and labelling measures prior to 9 January 2009 and enacted a comprehensive ban on all tobacco advertising, promotion and sponsorship prior to 9 January 2011. In addition, universal protection against secondhand tobacco smoke should have been implemented before 9 January 2011 by ensuring that all indoor workplaces, all indoor public places, all public transportation and possibly other (outdoor or quasi-outdoor) public places are free of secondhand smoke. The authors conducted a review of various sources of information to determine the current status of FCTC implementation in mainland China. Even though China has made considerable efforts to implement the FCTC, there is still a significant gap between the current state of affairs in China and the requirements of the FCTC. The Chinese tobacco monopoly under which commercial and other vested interests of the tobacco industry are jeopardising tobacco control efforts is thought to be the most crucial obstacle to the effective implementation of the FCTC across the country.

Mamudu HM; Hammond R; Glantz SA. International trade versus public health during the FCTC negotiations, 1999-2003. Tobacco Control 20(1): e-article 3, 2011. (147 refs.)

Objective To examine why the Framework Convention on Tobacco Control did not include an explicit trade provision and delineate the central arguments in the debate over trade provision during the negotiations. Methods Triangulate interviews with participants in the FCTC negotiations, the FCTC negotiations documents, and tobacco industry documents. Results An explicit FCTC trade provision on relation between international trade and public health became a contentious issue during the negotiations. As a result, two conflicting positions, health-over-trade and opposition to health-over-trade emerged. Opposition to explicit trade language giving health priority was by both tobacco industry and countries that generally supported strong FCTC provisions because of concerns over 'disguised protectionism' and setting a precedent whereby governments could forfeit their obligations under pre-existing treaties. Owing to lack of consensus among political actors involved in the negotiations, a compromise position eliminating any mention of trade emerged, which was predicated on belief among some in the public health community that public health would prevail in future trade versus health conflicts. Conclusion: The absence of an explicit FCTC trade provision was due to a political compromise rather than the impact of international trade agreements and decisions on public health and lack of consensus among health advocates. This failure to include an explicit trade provision in the FCTC suggests that the public health community should become more involved in trade and health issues at all levels of governance and press the FCTC Conference of the Parties for clarification of this critical issue.

Manubay JM; Muchow C; Sullivan MA. Prescription drug abuse: Epidemiology, regulatory issues, chronic pain management with narcotic analgesics. Primary Care 38(1): 71+, 2011. (52 refs.)

The epidemic of prescription drug abuse has reached a critical level, which has received national attention. This article provides insight into the epidemiology of prescription drug abuse, explains regulatory issues, and provides guidelines for the assessment and management of pain, particularly with long-term opioid therapy. Using informed consent forms, treatment agreements, and risk documentation tools and regularly monitoring the 4 A's help to educate patients and guide management based on treatment goals. By using universal precautions, and being aware of aberrant behaviors, physicians may feel more confident in identifying and addressing problematic behaviors.

Markowitz JD; Francis EM; Gonzales-Nolas C. Managing acute and chronic pain in a substance abuse treatment program for the addicted individual early in recovery: A current controversy. Journal of Psychoactive Drugs 42(2): 193-198, 2010. (42 refs.)

Patients early in recovery from addictive disorders are in a tenuous position and when these individuals are stressed from acute or chronic pain they face even more challenges. Physicians are often conflicted by the desire to help the patient achieve pain control and maintain sobriety. While there have been a handful of studies examining patients in either active addiction with pain or with a more remote history of addiction with pain, there have been very few, if any, that look at treating patients during their addiction recovery process who suffer from pain. This article will examine the issue of whether it is ever appropriate to use opioid pain medications on such patients and, if so, what guidelines can be used to maximize the chances of a good outcome while minimizing the chances of causing a recurrence or exacerbation of addiction.

Mayet S; Manning V; Sheridan J; Best D; Strang J. The virtual disappearance of injectable opioids for heroin addiction under the 'British System'. Drugs: Education, Prevention and Policy 17(5): 496-506, 2010. (25 refs.)

Aims: Injectable opioids were prescribed unsupervised under the 'British System' for heroin dependence. National guidelines (1999 and 2003) confirmed that injectable opioids have a legitimate 'limited clinical place' and should be dispensed daily, with 'mechanisms for supervision'. This study assesses whether national guidelines impacted on prescriptions of injectable opioids. Methods: A 25% random sample of community pharmacists (n = 2473) in England were surveyed by a questionnaire in 2005, with 95% response (n = 2349). Opioid maintenance prescription data for anonymous patients (n = 9620) were compared to the prescription data in 1995 (n = 3721) from a matched survey. Findings: Injectable opioid prescriptions reduced significantly from 10.5% (1995) to 1.8% (2005) of all opioid maintenance prescriptions. Daily doses significantly increased, as did daily dispensing from 28.8% (1995) to 57.8% (2005), whilst weekly dispensing reduced from 39.5% (1995) to 14.5% (2005). In 2005, injectable opioids accounted for 27.2% of private opioid prescriptions, versus 1.5% National Health Service (NHS) prescriptions. Private prescriptions were for larger take-home doses than NHS prescriptions. Regional variation was present. Conclusions: Injectable opioid maintenance treatment for heroin dependence under the unsupervised 'British System' is disappearing, although not extinct. If injectable opioids are prescribed, this is more in line with national guidelines. However, many prescriptions are less than daily instalments.

McIvor A; Kayser J; Assaad JM; Brosky G; Demarest P; Desmarais P et al. Best practices for smoking cessation interventions in primary care. (review). Canadian Respiratory Journal 16(4): 129-134, 2009. (25 refs.)

BACKGROUND: In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients. OBJECTIVE: To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients. METHODS: A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived front international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article. RESULTS: The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients' lives. CONCLUSION: Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.

McMenamin SB; Bellows NM; Halpin HA; Rittenhouse DR; Casalino LP; Shortell SM. Adoption of policies to treat tobacco dependence in U.S. medical groups. American Journal of Preventive Medicine 39(5): 449-456, 2010. (23 refs.)

Background: There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). Purpose: To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. Methods: During 2006-2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. Results: Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006-2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. Conclusions: There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

Moore E; Coffey C; Carlin JB; Alati R; Patton GC. Assessing alcohol guidelines in teenagers: Results from a 10-year prospective study. Australian and New Zealand Journal of Public Health 33(2): 154-159, 2009. (18 refs.)

Objective: To assess the value of drinking guidelines applied in adolescence for predicting alcohol-related outcomes in young adulthood. Methods: We conducted an eight-wave, population-based cohort study of 696 males and 824 females in Victoria between 1992 and 2003. Adolescent drinking was assessed at five survey waves, in six month intervals, from mean age 15.4-17.4 years. We created three measures of adolescent alcohol use using categories from NHMRC drinking guidelines: risky/high-risk drinking in the short and long term (2001), and high-risk drinking (2007). Each measure was defined according to the number of waves at which drinking was reported at or above the designated level during adolescence: non-drinkers, zero waves (low-risk drinkers), one wave, and 2+ waves. Alcohol use disorders and alcohol-related sexual behaviours were assessed at mean age 24.1 years. Results: Fourteen per cent of males and 17% of females were non-drinkers during adolescence. Using each NHMRC drinking guideline, the prevalence of each outcome for men increased with the number of waves at which drinking was reported above the low-risk level (p-values <0.007). The association was less clear for women. The prevalence of each outcome was lower among the nondrinkers compared to the low-risk drinkers for both men and women. Conclusions and implications: These findings support the emphasis in the NHMRC guidelines on abstaining from alcohol during the adolescent years. Any drinking, even at the low-risk level, may not be appropriate in adolescence. However, refinements that could better capture the risk of adolescent drinking in women would be useful.

Moreira M; Buchanan J; Heard K. Validation of a 6-hour observation period for cocaine body stuffers. American Journal of Emergency Medicine 29(3): 299-303, 2011. (13 refs.)

Often, patients are brought in to the emergency department after ingesting large amounts of cocaine in an attempt to conceal it. This act is known as body staffing. The observation period required to recognize potential toxic adverse effects in these patients is not well described in the literature. We sought to validate a treatment algorithm for asymptomatic cocaine body stuffers using a 6-hour observation period by observing the clinical course of cocaine body stuffers over a 24-hour period. A retrospective chart review was performed on all patients evaluated for witnessed or suspected stuffing over 2 years using a standardized protocol. One hundred six patients met final inclusion criteria as adult cocaine stuffers. No patients developed life-threatening symptoms, and no patients died during observation. In our medical setting, starers could be discharged after a 6-hour observation period if there was either complete resolution or absence of clinical symptoms.

Morrison KN; Naegle MA. An evidence-based protocol for smoking cessation for persons with psychotic disorders. Journal of Addictions Nursing 21(2-3): 79-86, 2010. (26 refs.)

Consequences of the use of tobacco products claim the lives of 443,000 Americans and 5.4 million persons worldwide every year. Persons with diagnosed psychiatric illnesses, including addiction, have the highest prevalence of smoking of any population, and smoke more intensely and heavily than others. In preparation for developing a step-wide protocol for a nursing intervention, recent literature on smoking cessation with smokers and those with psychiatric diagnoses was searched. A total of 16 related or specific studies and reviews were identified and critiqued, seeking support for interventions specific to the needs and attributes of this population. Few studies either included or focused on the smoking cessation with those having diagnoses of addiction and/or other psychiatric disorders, although study populations may have included such individuals. The results of research critiques suggest that standard approaches to smoking cessation have comparable success with the general population and persons with psychiatric disorders. The need to tailor interventions to achieve continued smoking cessation, however, remains an important need. The protocol steps are supported by the evidence drawn from the research literature and best practice guidelines.

Moss DR; Cluss PA; Watt-Morse M; Pike F. Targeting pregnant and parental smokers: Long-term outcomes of a practice-based intervention. Nicotine & Tobacco Research 11(3): 278-285, 2009. (42 refs.)

This study aimed to assess the change in obstetric and pediatric provider smoking cessation practices following implementation of a practice guideline-driven office-based program. This pre-post evaluation took place between May 2003 and August 2006 in 1 pediatric and 1 obstetric hospital-based clinic. The intervention involved provider training combined with office system supports. A total of 1,080 exit interviews were collected to measure outcomes of clinic practices at baseline and at 1 month, 6 months, 1 year (obstetric), and 2 years (pediatric) after implementation. Trend analysis was used to assess change in practice rates over time. Following program implementation, pediatric provider "Ask" rates increased (49% before to 86% 2 years after, p < .0001); changes in pediatric "Advise" and "Assist" rates were not significant: 44%-59% (p = .19) and 18%-28% (p = .26), respectively. In the obstetric clinic, whereas no significant changes were detected in provider "Ask" (59%-65% 1 year after, p = .17) or "Advise" (72%-85%, p = .27) rates, "Assist" rates rose from 28% to 62% (p = .0075) 1 year after program implementation. Implementation of the office-based program achieved significantly improved trends in pediatric provider "Ask" rates and obstetric provider "Assist" rates over time. Further research is needed on office strategies to create long-term provider behavior changes in smoking cessation practices.

Murin S; Rafii R; Bilello K. Smoking and smoking cessation in pregnancy. Clinics in Chest Medicine 32(1): 75-+, 2011. (90 refs.)

Smoking during pregnancy is among the leading preventable causes of adverse maternal and fetal outcomes. Smoking prevalence among young women is the primary determinant of smoking prevalence during pregnancy. Smoking among women of childbearing age is associated with reduced fertility, increased complications of pregnancy, and a variety of adverse fetal outcomes. There is increasing evidence of lasting adverse effects on offspring. Guidelines for smoking cessation during pregnancy have been developed. This article reviews the epidemiology of smoking during pregnancy, the adverse effects of smoking on the mother, fetus, and offspring, and recommended approaches to smoking cessation for pregnant women.

Nicolich RS; Padilha MC; Neto FRD. Study of the endogenous steroid profile of male athletes from the Brazilian National Soccer Championship 2009. Drug Testing and Analysis 2(11-12, special issue): 599-602, 2010. (19 refs.)

Changes in the endogenous profile of androgenic anabolic steroids (AAS) may be interpreted as markers of doping. The objective of this study was to evaluate the endogenous profile of AAS in male athletes of the 2009 Brazilian National Soccer Championship, in normal conditions, particularly in the light of the revision of World Anti-Doping Agency's (WADA) Technical Document on the Interpretation of Endogenous AAS in athletes for doping control drafted in that year, as well as comparing these results to profiles already published in the literature. The upper limit of the 95% central reference interval of the following parameters for the studied population were estimated to be significantly higher than WADA's criteria, with a confidence of 90%: DHEA (about 2.3 times higher), Adiol (1.2 times higher), Bdiol (2.7 times higher), and Adiol/E (6 times higher). These findings seem to imply that WADA's criteria proposed in 2009 for DHEA, Adiol, Bdiol, and Adiol/E may not have been applicable to the studied population. Moreover, their comparison to previously published studies pointed to the need to evaluate in detail the appropriateness of adopting these criteria as universal, since there seems to be variations among different populations of athletes.

Parrino M; AATOD Board Directors. QTc Interval Screening. American Association for the Treatment of Opioid Dependance (AATOD) Policy and Guidance Statement. (letter). Heroin Addiction and Related Clinical Problems 11(2): 59-61, 2009. (22 refs.)

Raw M; Regan S; Rigotti NA; McNeill A. A survey of tobacco dependence treatment guidelines in 31 countries. Addiction 104(7): 1243-1250, 2009. (16 refs.)

The Framework Convention on Tobacco Control (FCTC) asks countries to develop and disseminate comprehensive evidence-based guidelines and promote adequate treatment for tobacco dependence, yet to date no summary of the content of existing guidelines exists. This paper describes the national tobacco dependence treatment guidelines of 31 countries. A questionnaire on tobacco dependence treatment guidelines was sent by e-mail to a convenience sample of contacts working in tobacco control in 31 countries in 2007. Completed questionnaires were received from respondents in all 31 countries. During the course of these enquiries we also made contact with people in 14 countries that did not have treatment guidelines and sent them a short questionnaire asking about their plans to produce guidelines. The survey instrument was a 17-item questionnaire asking the following key questions: do the guidelines recommend brief interventions, intensive behavioural support, medications; which medications; do the guidelines apply to the whole health-care system and all professionals; do they refer explicitly to the Cochrane database; are they based on another country's guidelines; are they national or more local; are they endorsed formally by government; did they undergo peer review; who funded them; where were they published; do they include evidence on cost effectiveness of treatment? According to respondents, all their countries' guidelines recommended brief advice, intensive behavioural support and nicotine replacement therapy (NRT); 84% recommended bupropion; 19% recommended varenicline; and 35% recommended telephone quitlines. Nearly half (48%) included cost-effectiveness evidence. Seventy-one per cent were supported formally by their government and 65% were supported financially by the government. Most (84%) used the Cochrane reviews as a source of evidence, 84% underwent a peer review process and 55% were based on the guidelines of other countries, most often the United States and England. Overall, the guidelines reviewed followed the evidence base closely, recommending brief interventions, intensive behavioural support and NRT, and most recommended bupropion. Varenicline was not on the market in most of the countries in this survey when their guidelines were written, illustrating the need for guidelines to be updated periodically. None recommended interventions not proven to be effective, and some recommended explicitly against specific interventions (for lack of evidence). Most were peer-reviewed, many through lengthy and rigorous procedures, and most were endorsed or supported formally by their governments. Some countries that did not have guidelines expressed a need for technical support, emphasizing the need for countries to share experience, something the FCTC process is well placed to support.

Rieckmann T; Fuller BE; Saedi GA; McCarty D. Adoption of practice guidelines and assessment tools in substance abuse treatment. Substance Abuse Treatment, Prevention and Policy 5(e-journal 4), 2010. (38 refs.)

Background: The gap between research and practice limits utilization of relevant, progressive and empirically validated strategies in substance abuse treatment. Methods: Participants included substance abuse treatment programs from the Northeastern United States. Structural equation models were constructed with agency level data to explore two outcome variables: adoption of practice guidelines and assessment tools at two points in time; models also included organizational, staffing and service variables. Results: In 1997, managed care involvement and provision of primary care services had the strongest association with increased use of assessment tools, which, along with provision of counseling services, were associated with a greater use of practice guidelines. In 2001, managed care involvement, counseling services and being a stand-alone drug treatment agency were associated with a greater use of assessment tools, which was in turn related to an increase in the use of practice guidelines. Conclusions: This study provides managers, clinicians and policy-makers with a framework for understanding factors related to the adoption of new technologies in substance abuse treatment.

Robbins MS; Feaster DJ; Horigian VE; Puccinelli MJ; Henderson C; Szapocznik J. Therapist adherence in brief strategic family therapy for adolescent drug abusers. Journal of Consulting and Clinical Psychology 79(1): 43-53, 2011. (44 refs.)

Objective: Therapist adherence has been shown to predict clinical outcomes in family therapy. In prior studies, adherence has been represented broadly by core principles and a consistent family (vs. individual) focus. To date, these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinically relevant outcomes over the course of treatment. In this study, the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents who received brief strategic family therapy within a multisite effectiveness study. Method: Participants were 480 adolescents (age 12-17) and their family members, who were randomized to the Brief Strategic Family Therapist treatment condition (J. Szapocznik, U. Hervis. & S. Schwartz, 2003) or treatment as usual. The adolescents were mostly male (377 vs. 103 female) and Hispanic (213), whereas 148 were White, and 110 were Black. Therapists were also randomly assigned to treatment condition within agencies. Results: Results supported the proposed factor structure of the adherence measure, providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy. Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinically relevant ways and that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning, and reductions in adolescent drug use. Conclusions: Clinical implications and future research directions are discussed, including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy.

Saitz R. Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: Advocacy or evidence-based practice? Annals of Internal Medicine 153(1): 40-43, 2010. (18 refs.)

The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care.

Shawcross DL; O'Grady JG. The 6-month abstinence rule in liver transplantation. (editorial). Lancet 376(9737): 216-217, 2010. (12 refs.)

Singh I; Kendall T; Taylor C; Mears A; Hollis C; Batty M et al. Young people's experience of ADHD and stimulant medication: A qualitative study for the NICE Guideline. Child and Adolescent Mental Health 15(4): 186-192, 2010. (18 refs.)

Background: The NICE ADHD Guideline Group found a lack of research evidence on young people's experiences with stimulant medications. The present study was commissioned to help fill this gap in the evidence base and to inform the Guideline. Method: Focus groups and 1: 1 interviews with 16 UK young people with ADHD. Results: Young people were positive about taking medication, feeling that it reduced their disruptive behaviour and improved their peer relationships. Young people experienced stigma but this was related more to their symptomatic behaviours than to stimulant drug medication. Conclusions: The study's findings helped to inform the NICE guideline on ADHD by providing evidence that young people's experiences of medication were in general more positive than negative. All NICE Guidelines involving recommendations for the treatment of young people should draw on research evidence of young people's experiences of treatments.

Smith AJ; Tett SE. Improving the use of benzodiazepines-Is it possible? A non-systematic review of interventions tried in the last 20 years. BMC Health Services Research 10: e-article 321, 2010. (69 refs.)

Background: Benzodiazepines are often used on a long term basis in the elderly to treat various psychological disorders including sleep disorders, some neurological disorders and anxiety. This is despite the risk of dependence, cognitive impairment, and falls and fractures. Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide. The objective of this paper is to explore interventions aimed at improving the prescribing and use of benzodiazepines in the last 20 years. Methods: Medline, EMBASE, PsychINFO, IPA were searched for the period 1987 to June 2007. Results: Thirty-two articles met the study eligibility criteria (interventions solely focusing on increasing appropriate prescribing and reducing long term use of benzodiazepines) and were appraised. Insufficient data were presented in these studies for systematic data aggregation and synthesis, hence critical appraisal was used to tabulate the studies and draw empirical conclusions. Three major intervention approaches were identified; education, audit and feedback, and alerts. Conclusions: Studies which used a multi-faceted approach had the largest and most sustained reductions in benzodiazepines use. It appears that support groups for patients, non-voluntary recruitment of GPs, and oral delivery of alerts or feedback may all improve the outcomes of interventions. The choice of outcome measures, delivery style of educational messages, and requests by GPs to stop benzodiazepines, either in a letter or face to face, showed no differences on the success rates of the intervention.

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/

Stanger C; Budney AJ. Contingency management approaches for adolescent substance use disorders. Child and Adolescent Psychiatric Clinics of North America 19(3): 547-+, 2010. (44 refs.)

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations.

Streltzer J; Ziegler P; Johnson B. Cautionary guidelines for the use of opioids in chronic pain. American Journal on Addictions 18(1): 1-4, 2009. (19 refs.)

Guidelines for the use of opioids in the treatment of chronic pain have recently been proposed by the American Academy of Addiction Psychiatry. Older guidelines proposed by American pain organizations had the effect of liberalizing opioid prescription. In recent years, dramatic increases in prescribed opioids have been followed by equally dramatic rises in morbidity and mortality from prescription opioids. In addition, new research has increased knowledge of the long-term effects of opioids. These new guidelines propose increased caution in regard to opioid prescription for chronic pain.

Tetzlaff J; Collins GB; Brown DL; Leak BC; Pollock G; Popa D. A strategy to prevent substance abuse in an academic anesthesiology department. Journal of Clinical Anesthesia 22(2): 143-150, 2010. (18 refs.)

Substance abuse is the most serious occupational safety issue associated with the practice of anesthesiology, with an incidence as high as 1% per year of training. The Cleveland Clinic's Anesthesiology Institute approached the process from the perspective of active prevention, including specific mandatory education programs for all department personnel on a recurring basis, strengthened procedures for the detection and prevention of diversion of controlled substances, enhanced skill building for detection of impairment, and implemented a multi-faceted drug testing program, including random and for cause" urine screens, for prevention and early detection of abused anesthetic drugs and other substances of abuse. After 18 months of preparation, a Substance Abuse Prevention Protocol was created, which has been fully implemented as of September 1, 2007.

Thevis M; Kuuranne T; Geyer H; Schanzer W. Annual banned-substance review: Analytical approaches in human sports drug testing. (review). Drug Testing and Analysis 3(1): 1-14, 2011. (122 refs.)

The timely update of the list of prohibited substances and methods of doping (as issued by the World Anti-Doping Agency) is an essential aspect of international anti-doping efforts and represents consensual agreement by expert panels regarding substances and the methods of performance manipulation in sports. The annual banned-substance review for human doping controls critically summarizes recent innovations in analytical approaches; its purpose is to improve the quality of doping controls by reporting emerging and advancing methods that focus on detecting known and recently outlawed substances. This review surveys new and/or enhanced procedures and techniques of doping analysis together with information relevant to doping control that has been published in the literature between October 2009 and September 2010.

Tonje L; Elisabeth S; Lars W. Handling of drug-related emergencies: an evaluation of emergency medical dispatch. European Journal of Emergency Medicine 16(1): 37-42, 2009. (27 refs.)

Aims: Documenting the quality of emergency dispatch centres handling of emergency calls regarding intoxicated unconscious patients. Methods: Interview with eight emergency dispatch centre directors and a nationwide survey among 313 dispatchers in Norway were performed. In addition, a customized scoring system was used to evaluate dispatcher log recordings of real cases. The recordings were compared with information from corresponding ambulance records. Results: Ninety-nine percent of the dispatchers stated that they used the Norwegian protocol for medical emergencies and 89% of them found it useful. The interviews, the survey, and the recordings, however, documented frequent deviation from the protocol. This instructs ambulance dispatch for any unconscious patient, but 21% stated that they would not dispatch any resource for an unconscious patient without further survey in alcohol-related cases. This was significantly more often (P < 0.05) than for the narcotic, combination and prescription -drug-related cases with 4, 10 and 7%, respectively. The recordings revealed deviation from the protocol with dispatchers only determining the patients' level of consciousness and respiratory status in 64 and 70% of the cases, respectively. For 16% of the cases, the dispatcher did not ask the caller about consciousness at all, even though these patients later were found with reduced consciousness. Conclusion: On the basis of the interviews and the survey, cases were handled according to guidelines. The log recordings, however, disclosed deviation from the protocol. Alcohol intoxication was associated with higher rate of deviation from the protocol compared with other intoxications.

Tonstad S. Smoking cessation: How to advise the patient. Heart 95(19): 1635-1640, 2009. (20 refs.)

Observations show that only one third to one half of patients who smoke at the time of myocardial infarction subsequently manage to quit. This indicates that many smokers do not receive optimal medical support for cessation. There is often a gap between hospital discharge and follow-up by the primary care physician. Cardiologists and hospital physicians potentially play a key role in motivating and supporting quitting behaviour and should not assume that primary care physicians will fill the gap. The 5 A's (ask, assess, advise, assist, arrange) have been adopted by the European Society of Cardiology as an effective strategy to promote smoking cessation. Smokers should be identified systematically by hospital and office operating procedures. All notes should include an up to date record of smoking status. When a patient is identified as a smoker, the consultant physician or cardiologist intervenes by: (1) assessing dependence on cigarettes; (2) personalising benefits of cessation; (3) boosting motivation for a quit attempt; (4) recommending and prescribing medication; (5) discussing behavioural changes and setting a quit date; and (6) arranging follow-up. The combination of support (motivational, social) and pharmacotherapy has been shown to be the most effective treatment for patients with CVD

Tran DT; Stone AM; Fernandez RS; Griffiths AMRD; Johnson M. Does implementation of clinical practice guidelines change nurses' screening for alcohol and other substance use? Contemporary Nurse 33(1): 13-19, 2009. (22 refs.)

Aim: To examine the effectiveness of the implementation of a clinical practice guideline on nurses screening patients for alcohol and other substance use, providing, brief interventions, and referring patients at risk for treatment. Method. Medical record audits were conducted in selected medical and surgical wards of two metropolitan hospitals in Sydney prior to and three months follow I rig the guideline implementation. Result. Seventy-nine (pre) and 84 (post) patient records were audited. There were no differences in screening rates for alcohol (28% and 29 9,6), tobacco (29% and 23%) and illicit drug use (16% and 8%) before and after implementation of the guideline. Practice implication: Factors which may have limited the effectiveness of the clinical practice guideline dissemination included design of the education program, existing level of nurses' knowledge and competence, and strategies in place to ensure sustainability of the program. We also provided suggestions for improvement of screening for alcohol and other substance use.

Wesson DR; Smith DE. Buprenorphine in the treatment of opiate dependence. (review). Journal of Psychoactive Drugs 42(2): 161-175, 2010. (113 refs.)

Compelling clinical evidence establishes that buprenorphine is similar to methadone in efficacy for opiate detoxification and maintenance but safer than methadone in an overdose situation. The Drug Abuse Treatment Act of 2000 (DATA 2000) enabled US physicians with additional training to prescribe buprenorphine to a limited number of opiate-dependent patients. The sublingual tablets Subutex (R) (buprenorphine alone) and Suboxone (R) (a combination of buprenorphine and naloxone) meet the specifications of DATA 2000. Suboxone is intended to discourage intravenously administration and has less abuse potential than buprenorphine alone. Suboxone is generally recommended for maintenance treatment except for women who are pregnant. Subutex is recommended in treatment of pregnant women. A buprenorphine opiate withdrawal syndrome can occur in newborns. Although intravenous buprenorphine abuse is a significant public health problem in some countries, buprenorphine alone or in combination with naloxone has less potential for abuse than heroin and some prescription opiates, such as oxycodone. Pharmacotherapy from physicians' offices makes buprenorphine treatment acceptable to some opiate-dependent patients who would not accept treatment in traditional opiate-maintenance clinics. For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult. This article reviews the pharmacology of buprenorphine, summarizes evidence supporting the safety and efficacy of buprenorphine and provides clinical guidelines for treatment.

Willenbring ML; Massey SH; Gardner MB. Helping patients who drink too much: An evidence-based guide for primary care physicians. American Family Physician 80(1): 44-50, 2009. (27 refs.)

Excessive alcohol consumption is a leading cause of preventable morbidity and mortality, but few heavy drinkers receive treatment. Primary care physicians are in a position to address heavy drinking and alcohol use disorders with patients, and can do so quickly and effectively. The National Institute on Alcohol Abuse and Alcoholism has published a guide for physicians that offers an evidence-based approach to screening, assessing, and treating alcohol use disorders in general health care settings. Screening can be performed by asking patients how many heavy drinking days they have per week. Assessing patients' willingness to change their drinking behaviors can guide treatment. Treatment recommendations should be presented in a clear, nonjudgmental way. Patients who are not alcohol-dependent may opt to reduce drinking to lower risk levels. Patients with alcohol dependence should receive pharmacotherapy and brief behavioral support, as well as disease management for chronic relapsing dependence. All patients with alcohol dependence should be encouraged to participate in community support groups.

Wilsey BL; Fishman SM; Casamalhuapa C; Gupta A. Documenting and improving opioid treatment: The Prescription Opioid Documentation and Surveillance (PODS) System. Pain Medicine 10(5): 866-877, 2009. (36 refs.)

Objective. To demonstrate that a computer-assisted survey instrument offers an efficient means of patient evaluation when initiating opioid therapy. Design. We report on our experience with the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that uses validated questionnaires to collect comprehensive clinical and behavioral information from patients with chronic pain. Setting and Patients. Over a 39-month period, 1,400 patients entered data into PODS using a computer touch screen in a Veterans Administration Pain Clinic. Measures. Indices of pain intensity, function, mental health status, addiction history, and the potential for prescription opioid abuse were formatted for immediate inclusion into the medical record. Results. The PODS system offers physicians a tool for systematic evaluation prior to prescribing opioids The system generates an opioid agreement between the patient and physician, and provides medicolegal documentation of the patient's condition. Conclusions. PODS should improve patient care, refine pain control, and reduce the incidence of opioid abuse. Research to determine how PODS affects clinical care is underway. Specially, the effectiveness and efficiency of providing care utilizing PODS will be evaluated in future studies.