Cork Newsletter. Primary Care. Fall. 2002

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...Primary Care

www.ProjectCork.org

Fall 2002

Impediments to screening for hazardous alcohol use and dependence in general hospital psychiatric inpatients.

Hulse GK. Australian and New Zealand Journal of Psychiatry 35(5): 606-612, 2001. (26 refs.)
Objective: The Alcohol Use Disorders Identification Test (AUDIT) has been developed to screen for hazardous and harmful alcohol consumption. It has been used among a variety of primary care, general population and general hospital populations. However, with the exception of one study undertaken by the author and colleagues, the use of the AUDIT in general hospital psychiatric patients has not been reported. This paper reports on a substudy of this larger study whose aim was to determine the frequency of hazardous alcohol use and dependence among patients admitted to the psychiatric units of general hospitals in Perth, Western Australia, and discusses major reasons for non-AUDIT screening among this group. Method: In a 12-month period 990 patients aged 18-64 years and residing in the Perth metropolitan area were admitted to the psych-iatric unit of the two hospitals. Using the AUDIT alcohol use in patients with four major types of psychiatric dis-order, namely mood, adjustment, anxiety and psychotic disorders, was assessed. Results: Of the 834 admissions targeted for AUDIT screening 263 were not screened. This non-screening represented 27-42% of patients in each of the major diagnostic categories, There was no significant difference in the proportion of patients screened versus not screened for mood, adjustment or schizophrenia/psychosis. There were however, significantly fewer patients with anxiety disorder screened compared with mood disorder. Those non-screened patients in major psychiatric groups had significantly shorter hospital stays than their diagnostic counterparts who were screened. The major reason for non-screening in all groups was due to patients leaving the psychiatric facility before they could be accessed. This included discharge before screening, transfer to another psychiatric facility and short admission. To a lesser extent cognitive dysfunction accounted for non-screening among major diagnostic groups. Conclusions: Failure to screen patients was largely due to short hospital stays. Screening was impeded by the brief window period, commonly 1 or 2 days, between the absence of acute psychiatric sequelae and discharge. This situation contrasts dramatically to the medical or surgical admission where major sequelae are largely resolved in 2-3 days and AUDIT screening can take place over the remaining 3-4 days prior to discharge. To be effective in the general hospital psychiatric setting, alcohol screening needs to be incorporated into the routine ward assessment procedures. The brevity of the AUDIT makes this possible. This would maximize the time available to implement an intervention programme to those found to be consuming alcohol at a hazardous or harmful level.

Physician behavior towards male and female problem drinkers: A controlled study using simulated patients.

Wilson L; Kahan M; Liu E; Brewster JM; Sobell MB; Sobell LC. Journal of Addictive Diseases 21(3): 87-99, 2002. (26 refs.)
Background: Evidence suggests that physicians are less likely to identify alcohol problems in females than in males. Purpose: To compare the performance of family medicine residents with male and female simulated patients (SPs) posing as problem drinkers. Methods: Fifty-six family medicine residents completed a baseline survey on knowledge and attitudes towards problem drinkers. Each resident was then visited by one male and female unannounced SP. The male and female roles were similar with respect to presenting complaint (insomnia or hyper-tension), age, social class, and drinking history. Results: Residents expressed slightly more positive attitudes towards female than male patients (3.32 vs. 3.09, p < .001). Residents scored higher with undetected male than with undetected female SPs on the assessment checklist (5.1 vs. 3.2, p < .045), the management checklist (4.4 vs. 3.2, p = .032), and an interpersonal rating scale (the Alcohol Skills Rating Form; 5.5 vs. 4.7, p = .023). Conclusion: Educational programs should focus on improving physicians' clinical skills in the identification and treatment of alcohol problems in women.

Smoking cessation in a homeless population: There is a will, but is there a way?

Connor SE; Cook RL; Herbert M; Neal SM; Williams JT. Journal of General Internal Medicine 17(5): 369-372, 2002. (23 refs.)
This cross-sectional study sought to determine the prevalence of smoking, readiness to quit, and preferences for smoking cessation treatments among a sample of 236 homeless adults attending 9 sites serving homeless persons (mean age 41.8 years; 73% male). Two thirds (69%) were current smokers, of whom 37% reported readiness to quit smoking within the next 6 months. In bivariate analyses, persons were significantly (P < .05) more likely to be ready to quit if they had tried to quit in the past and if they had social support to quit smoking. Nicotine replacement was the most commonly preferred assistance method (44%), and self-efficacy to quit (10-point scale) was significantly greater if assistance was available (7.3 vs. 4.9; P < .001). The findings suggest an urgent need to dev-elop and implement smoking cessation programs for homeless persons.

Alcohol use disorders in primary care: Do gender-specific differences exist? (review).

Brienza RS; Stein MD. Journal of General Internal Medicine 17(5): 387-397, 2002. (142 refs.)
OBJECTIVE: To describe how alcohol use disorders (AUDs) affect women, focusing on gender-specific Implications for primary care physicians (PCPs). DE-SIGN: An overview of literature from 1966 to 2000 Identified by a MEDLINE, PsychINFO and Health-STAR/Ovid Healthstar database search using key words "women," "alcohol" and "alcoholism." MEASURE-MENTS AND MAIN RESULTS: Although the prevalence of AUDs is greater in men than in women, women with AUDs are more likely to seek help, but less likely to be identified by their physicians. Psychiatric comorbidities (especially depression and eating disorders) are more common in women with AUDs than in men with AUDs. A past history of sexual and/or physical abuse places a woman at Increased risk for AUDs. Women have a greater sensitivity to alcohol, have an accelerated progression from alcohol toxicity, and have increased mortality at lower levels of consumption compared to men. Women and men who are light-to-moderate drinkers have lower coronary artery disease mortality than do abstainers or heavy drinkers. Risk of breast cancer is increased in women who drink greater than or equal to1 drinks daily. Common barriers to treatment include: fear of abandon-ment by partner; fear of loss of children; and financial dependency. Brief interventions have been shown to be effective in reduction of alcohol consumption in women with at-risk drinking. It is unclear if women-only treatment programs improve outcomes. CONCLUSION: PCPs should be alert to gender-specific differences for women with AUDs.

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking.

Bradley KA; Epler AJ; Bush KR; Sporleder JL; Dunn CW; Cochran NE et al. Journal of General Internal Medicine 17(5): 315-326, 2002. (40 refs.)
OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audio taped appointments collected over 6 months. PARTICI-PANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N = 47) and providers (N = 17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTER-VENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), Information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected "resistance" to change and 12% reflected readiness to change. On aver-age, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs. 39.6% of visits; P = .026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted.

At-risk drinking among patients in an occupational medicine clinic.

Curry SJ; Ludman E; Grothaus L; Gilmore T; Donovan D. Alcohol and Alcoholism 37(3): 289-294, 2002. (28 refs.)
This study described the prevalence and characteristics of at-risk drinkers among adults receiving care at an urban occupational medicine clinic. Comparisons were also made between occupational medicine and primary care patients. Among occupational medicine patients, preval-ences were: 11% at-risk drinking; 51% light-moderate drinking; 38% abstinence. Abstainers differed from alcohol users with regard to race (fewer Caucasian) and marijuana use (lower rates). Compared to light-moderate drinkers, at-risk drinkers were more likely to be smokers. Compared to a primary care sample, non-at-risk drinkers in occupational medicine reported poorer health, more activity limitations, higher rates of smoking and more stress and depressive symptoms. In contrast, at-risk drinkers in occupational medicine were quite similar to those in primary care. Occupational medicine clinics are viable settings in which to screen for at-risk drinking patterns and to implement primary and secondary prevention strategies.

Detection of alcohol and drug problems in an urban gynecology clinic.

Gupman AE; Svikis D; McCaul ME; Anderson J; Santora PB. Journal of Reproductive Medicine 47(5): 404-410, 2002. (19 refs.)
OBJECTIVE: To compare screening instruments for their utility to detect substance use problems in women seeking gynecologic care, to assess the likelihood that alcohol/drug problems mill be detected by physicians during a routine office visit and to examine the relationship between regular alcohol and/or drug use and the patient's presenting gynecologic complaints. STUDY DESIGN: Women (N = 360) attending a hospital-based gynecology clinic were screened prior to physician visit using the Michigan Alcoholism Screening Test, CAGE and T-ACE. After the visit, information on presenting complaint and physician's documentation of the patient's tobacco, alcohol and other drug use was abstracted from the medical record. RESULTS: The rates of alcohol and illicit drug use varied across assessment instruments; physician documentation, however, yielded the lowest prevalence estimates. Regular alcohol and drug users were more likely to present with chronic and acute medical problems than patients who were not regular users of these substances. CONCLU-SION: The gynecology clinic offers an opportunity for early identification of women with substance problems, and alternative strategies are needed to encourage gynecologists to routinely screen for such problems at each medical visit.

Does maternal smoking have a negative physiological effect on breastfeeding? The epidemiological evidence.

Amir LH; Donath SM. Birth Issues in Perinatal Care 29(2): 112-123, 2002. (93 refs.)
Background: Women who smoke are less likely to breastfeed their children than nonsmokers. It is thought that nicotine has a negative effect on breastmilk supply by suppressing prolactin levels. The aim of this review was to assess the epidemiological evidence that maternal smoking has a negative physiologieal effect on breastfeeding. Methods: The following data sources were searched: The Cochrane Library, Medline, CINAHL, Current Contents, Psychinfo, Sociological Abstracts and the Lactation Resource Centre (Australian Breastfeeding Association) using the keywords "smoking" and "breastfeeding" or "infant feeding." The Journal of Human Lactation and Birth were hand searched. Results: Women who smoke are less likely to intend to breastfeed, less likely to initiate breastfeeding, and likely to breastfeed for a shorter duration than nonsmokers. Several studies have found a dose-response relationship between the number of cigarettes smoked each day and breastfeeding intention, initiation, and duration that persists after adjusting for confounding factors. In some population groups a high proportion of smokers breastfeed successfulIy. Conclu-sions: The association between maternal smoking and lack of breastfeeding is consistent across different study designs in a range of countries. Given that women who smoke are less likely to intend to breastfeed, however, it cannot be assumed that the relationship between smoking and duration of breastfeeding is a physiological one. If smoking had a consistent negative physiological effect on lactation, one would not expect to see such wide variations in breastfeeding rates among women who smoke. Therefore, it is likely that psychosocial factors are largely responsible for the lower rates of breastfeeding found in women who smoke compared with those who do not.

Evaluating primary care behavioral counseling interventions: An evidence-based approach. (review)

Whitlock EP; Orleans CT; Pender N; Allan J. American Journal of Preventive Medicine 22(4): 267-284, 2002. (137 refs.)
Overview: Risky behaviors are a leading cause of preventable morbidity and mortality, yet behavioral counseling interventions to address them are underutilized in healthcare settings. Research on such interventions has grown steadily, but the systematic review of this research is complicated by wide variations in the organization, content, and delivery of behavioral interventions and the lack of a consistent language and framework to describe these differences. The Counseling and Behavioral Inter-ventions Work Group of the United States Preventive Services Task Force (USPSTF) was convened to address adapting existing USPSTF methods to issues and chal-lenges raised by behavioral counseling intervention topical reviews. The systematic review of behavioral counseling interventions seeks to establish whether such interventions addressing individual behaviors improve health outcomes. Few studies directly address this question, so evidence addressing whether changing individual behavior improves health outcomes and whether behavioral counseling inter-ventions in clinical settings help people change those behaviors must be linked. To illustrate this process, we present two separate analytic frameworks derived from screening topic tools that we developed to guide USPSTF behavioral topic reviews. No simple empirically validated model captures the broad range of intervention com-ponents across risk behaviors, but the Five A's construct-assess, advise, agree, assist, and arrange-adapted from tobacco cessation interventions in clinical care provides a workable framework to report behavioral counseling intervention review findings. We illustrate the use of this framework with general findings from recent behavioral counseling intervention studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations based on these reviews for specific behaviors.

Effect of a GP desktop resource on smoking cessation activities of general practitioners.

McEwen A; Preston A; West R. Addiction 97(5): 595-597, 2002. (6 refs.)
Objectives: To evaluate an intervention aimed at increasing the quantity and quality of brief opportunistic general practitioner (GP) advice to smokers encouraging and supporting quit attempts. Design: Randomized controlled trial with two groups: (1) control and (2) GP desktop resource (GDR). Smoking cessation activities of GPs were assessed by an independent postal survey 1 month after distribution of resource. Subjects and setting One hundred and seven GPs in West Dorset. Main outcome measures GPs' self-reported rates of advising and Counselling smokers on cessation over the previous week. Results: The rate of opportunistic advice per week in the GDR group was 4.9 (SD = 4.1), compared with 2.8 (SD = 1.8) in the control group, F = 8.2. p = 0.0025, one-tailed. The rate of giving counselling was also higher 2.2 (SD = 3.2) in the intervention group versus 1.0 (SD = 1.4) in the control group. F = 4.0, p = 0.025, one- tailed. The proportion who had recommended or prescribed NRT was greater, although not significantly (54% versus 46%, Fisher's exact p = 0.1, one-tailed). Conclusions: The findings indicate that the GDR can increase the rate of delivery of opportunistic advice and provision of counselling. Given the importance of this activity, a larger trial appears to be warranted to examine the long-term effect and the effect on cessation rates in patients.

Methadone maintenance treatment can be provided in a primary care setting without increasing methadone-related mortality: The Sheffield experience 1997-2000

Keen J//Oliver P//Mathers N. British Journal of General Practice 52(478): 387-389, 2002 (7 refs.)
Methadone maintenance treatment has been shown in manly studies to reduce mortality and morbidity among heroin users. However there has been concern that widespread methadone prescribing will lead conversely to an increase in methadone-related deaths. This study in Sheffield shows no increase in methadone-related mortality over a two- year period, during which 400 untreated patients were recruited into primary care methadone treatment in the city.

Beyond alcoholism: Identifying older, at-risk drinkers in primary care.

Moore AA; Beck JC; Babor TF; Hays RD; Reubens DB Journal of Studies on Alcohol 63(3): 316-324, 2002. (36 refs)
Objective: To evaluate the validity and reliability of two self- report instruments: the Alcohol-Related Problems Survey (ARPS) and its shorter version the Short ARPS (shARPS) that identify older persons whose use of alcohol alone or with their comorbidities may be placing them at risk for or causing them harm. Method: We compared the two measures against a "LEAD" (longitudinal evaluation done by experts employing all available data) standard among a sample of 166 drinkers aged 60 years and older in 10 internal medicine clinics. The LEAD standard included a medical record review, a clinical interview and a telephone interview with a collateral informant. We tabulated reasons the LEAD identified subjects as harmful or hazardous drinkers. We also compared the Alcohol Use Disorders Identification Test (AUDIT) and the Short Michigan Alcoholism Screening Test- Geriatric Version (SMAST-G) to the LEAD. Results: Sensitivity and specificity of the ARPS and the shARPS as compared to the LEAD were 93% and 63%, and 92% and 51%, respectively. After minor changes were made in the scoring rules, specificity increased to 66% for both the ARPS and shARPS while sensitivity remained stable. 93% and 91%. Harmful and hazardous drinkers were most often identified because of alcohol use with comorbidities, symptoms, and medication use. Sensitivity and specificity of the AUDIT and the SMAST-G as compared to the LEAD were 28% and 100%, and 52% and 96%, respectively. Conclusions: The ARPS and shARPS are quite sensitive in identifying older drinkers with a spectrum of alcohol use disorders. They are more sensitive than the AUDIT and the SMAST-G in identifying older persons who may be at risk or experiencing harm as a result of their alcohol use and comorbidities. They also provide information on specific risks associated with alcohol use not obtained by other screening measures and may therefore facilitate interventions by busy clinicians to reduce such risks.