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...on Substance use
in Primary Care

www.ProjectCork.org

Summer 2002

Alcoholic drinks and asthma.

(review)
Vally H; Thompson PJ. Clinical and Experimental Allergy 32(2): 186-191, 2002. (67 refs.)
Alcoholic drinks appear to play an important role in the triggering of asthma in certain individuals. Alcohol itself seems to play a relatively minor role, but is important in certain ethnic groups. In Caucasians, the nonalcohol components of alcoholic drinks, or congeners, seem to be the most important triggers for asthma, with the chemically more complex drinks appearing to be more often associated with these sensitivities. Wine is clearly the most commonly reported trigger for asthma, however, our understanding of the mechanisms underlying wine induced asthma is not clear. Wine induced asthma appears to be a multifactorial phenomenon, and evidence suggesting a role for IgEmediated allergy, as well as sensitivities to histamine and the sulfite additives in certain individuals have been reported. In many individuals, however, confirmation of sensitivity to wine in the challenge laboratory has proven difficult, suggesting a complex pathophysiology. It has been speculated that baseline asthma stability, as well as environmental cofactors, may play a role in sensitivity to wine in many individuals, and that this may explain the paucity of responses to challenge in clinical settings. Consequently, more sophisticated challenge strategies, as well as techniques which may provide more sensitive measurements of changes in airway function following wine challenge, may need to be explored if we are to further our understanding of asthmatic responses to wine.

Alcohol intake in rheumatic disease: Good or bad?

(review)
Sofat N; Keat A. Rheumatology 41(2): 125-128, 2002. (38 refs.)
Alcohol is a major cause of morbidity and mortality. Recent developments in basic science and clinical research have led to an improved understanding of the mechanisms of the effects of alcohol on musculoskeletal diseases. Alcohol can have harmful effects on the musculoskeletal system. It is associated with osteoporosis and an increased incidence of fractures. The strongest link is seen in spinal osteoporosis, where alcoholic men are most at risk. Ethanol promotes bone loss in both men and women. Excessive alcohol intake can lead to myopathies, which could lead to increased susceptibility to falls, possibly resulting in osteoporotic fractures, as described above. However, alcohol-induced myopathies themselves can exist in acute and chronic forms. In acute muscle injuries such as are seen in rhabdomyolysis, alcohol accounts for at least 20% of cases. Ethanol triggers muscle necrosis, resulting in derangement of oxidative or glycolytic energy production and ATP depletion. Animal and human studies have shown that chronic alcohol use results in negative nitrogen balance resulting from net catabolism of skeletal muscle proteins. A prolonged imbalance of protein metabolism leads to the erosion of lean body mass and the proximal myopathy seen in alcoholics. Although alcohol affects all muscle groups to some extent, the fast-twitch type-II fibres appear to be particularly vulnerable. The rate of protein synthesis in skeletal muscle has been examined by stimulating alcohol intoxication, showing that the rate of protein synthesis was reduced in humans In other rheumatic diseases, such as ankylosing spondylitis, alcohol has also been shown to have a detrimental effect. Alcohol also requires consideration in some of the treatments used for rheumatic diseases. Most guidelines recommend abstention from alcohol with the use of certain disease-modifying therapy. The most notable example is methotrexate. The risk of serious adverse hepato-toxicity is increased with concomitant alcohol intake.

Pediatric Clinics of North America

49(2): entire issue

2002. Thirteen article in this thematic issue.

Ą Prevention and risk of adolescent substance abuse: The role of adolescents, families, and communities. (39 refs.)

Reviews prevalence of substance use among adolescents, theoretical constructs to explain engagement in risk behaviors, and risk and protective factors for substance use.

Ą Adolescent substance abuse: Assessment in the office. (78 refs.)

Discussion of screening and evaluation; outlines clinical clues and laboratory assessment, reviews individual, family, and environmental risk factors. Useful mnemonics

Ą Adolescent substance abuse: Confidentiality and consent. (43 refs.)

Describes the legal and ethical basis of adolescent confidentiality and consent.

ĄUrine drug screening in adolescents. (31 refs.)

Considers urine drug screen as part of comprehensive evaluation, procedures for obtaining a valid and helpful urine drug screen, interpreting positive and negative results.

ĄOffice-based intervention for adolescent substance abuse. (51 refs.)

Outlines a number of strategies and clinical tools that appear promising with adolescents

ĄTreatment and relapse prevention for adolescent substance abuse. (93 refs.)

Reviews treatment: family treatments, cognitive behavioral techniques, motivation interviewing and 12-step approaches

ĄAlcohol advertising and adolescents. (93 refs.)

Teens view an average of 2,000 beer and wine ads per year in the US É.

ĄReducing tobacco use among youth. (22 refs.)

Discusses strategies to prevent young people from taking up the habit, and approaches to cessation

ĄMarijuana use among adolescents. (review). (197 refs.)

Reviews prevalence, acute actions, and long term problems.

ĄSupplements and drugs used to enhance athletic performance. (review). (141 refs.)

Reviews the physiology, clinical usage patterns, and efficacy, dosages, and adverse side effects of the use of drugs and supplements

ĄAdolescent substance use disorders and comorbidity. (87 refs.)

Comprehensive literature review of risk factors.

Ą MDMA ('ecstasy') and other 'club drugs' - The new epidemic. (116 refs.)

Discusses epidemiologic and neuropharmacologic data on acute and long term effects.

Medicaid patients in a private health maintenance organization: Patterns of chemical dependency treatment.

Walter LJ; Parthasarathy S; Allen S; Ackerson L. Journal of Behavioral Health Services & Research 29(1): 1-14, 2002. (33 refs.)
Although many Medicaid beneficiaries receive health care through commercial health maintenance organizations (HMOs), the impact of private managed care on low-income individuals seeking treatment for substance abuse has rarely been studied. This study examined treatment patterns of 234 Medicaid recipients who presented for care at an HMO between 1995 and 1997. After adjustment for demographic factors and duration of health plan membership, the Medicaid patients returned to start treatment after intake less often (odds ratio = 0.60) and dropped out of treatment sooner (median = 14 versus 28 days) than non-Medicaid patients. While many Medicaid patients received significant amounts of substance abuse treatment, further research is needed to explain the observed treatment gap and to identify areas where HMOs can improve services for some of their most vulnerable members.

Caught in the middle: Receptionists and their dealings with substance misusing patients.

Heuston J; Groves P; Al Nawad J; Albery I; Gossop M; Strang J. Journal of Substance Use 6(3): 151-157, 2001. (32 refs.)
This study examined the primary healthcare receptionist and their behavior, reactions, and interactions with substance abusing patients. The receptionist is an integral part of the primary healthcare team, however, the role of the receptionist with substance misusing patients has not been previously examined. Questionnaires were given to 72 receptionists in general practices in southeast London, of which 57 responded (76 percent). Almost half had experienced difficulties with substance misusing patients and thought they were the most difficult sort of patients. About a quarter of the receptionists thought that these patients should not be treated in general practice and just over half wanted some form of training or support. If substance misusing patients are to be treated in general practice, further consideration needs to be given to receptionists, who may benefit from training, support and a fuller appreciation of their contribution in the management of patients.

Problem drinking and alcoholism: Diagnosis and treatment.

Enoch MA; Goldman D. American Family Physician 65(3): 441-448, 2002. (35 refs.)
Alcoholism is one of the most common psychiatric disorders with a prevalence of 8 to 14 percent. This heritable disease is frequently accompanied by other substance abuse disorders (particularly nicotine), anxiety and mood disorders, and antisocial personality disorder. Although associated with considerable morbidity and mortality; alcoholism often goes unrecognized in a clinical or primary health care setting. Several brief screening instruments are available to quickly identify problem drinking, often a pre-alcoholism condition. Problem drinking can be successfully treated with brief intervention by primary care physicians. Alcohol addiction is a lifelong disease with a relapsing, remitting course. Because of the potentially serious implications of the diagnosis, assessment for alcoholism should be detailed. Alcoholism is treated by a variety of psychosocial methods with or without newly developed pharmacotherapies that improve relapse rates. Screening for problem drinking and alcoholism needs to become an integral part of the routine health screening questionnaire for adolescents and all adults, particularly women of child-bearing age, because of the risk of fetal alcohol syndrome.

Changing patient characteristics with increased methadone maintenance availability.

Brands B; Blake J; Marsh D. Drug and Alcohol Dependence 66(1): 11-20, 2002. (18 refs.)
Over the past several years there have been repeated calls for expansion of availability of methadone maintenance in several jurisdictions. Important stakeholders in the expansion of methadone maintenance treatment (MMT) are existing treatment providers. This study describes the impact of the rapid expansion in treatment availability in Ontario on the long-standing MMT program of the Centre for Addiction and Mental Health (CAMH). This expansion occurred through enlarging existing treatment programs. The provision of MMT in private physicians' offices and the establishment of new clinics. With expansion in the community demand for the clinic-based treatment of the CAMH MMT program did not drop. In fact the patient population was able to continue to grow. There was a broadening of the patient profile in the program including patients who were better educated. more likely to be employed and less likely to be currently injecting (although with a significant history of past injection drug use). Moreover, in the face of these changes, excellent treatment retention was maintained. This suggests that the expansion in treatment availability did not impact negatively on the existing program but rather enabled access for a group of higher 9 functioning opioid dependent patients who were preciously being deterred from treatment entry by the large waiting lists and the need for priority access for pregnant and HIV positive heroin users. These findings should provide encouragement for MMT providers in jurisdictions anticipating or undergoing expansion of treatment availability.

Primary health care professionals' activity in intervening in patients' alcohol drinking: A patient perspective.

Aalto M; Pekuri P; Seppa K. Drug and Alcohol Dependence 66(1): 39-43, 2002. (30 refs.)
Aim: To test the hypothesis that primary health care professionals' activity in intervening in patients' alcohol drinking is low. Method: A patient questionnaire Survey after Consultation blind to the primary health care professionals. Subjects were 1000 16-65-year-old consecutive patients consulting a general practitioner. The response rate was 66.5%. Results: Of all participants 6.3% and of excessive drinkers 11.9% were asked about alcohol drinking in the consultation in question. Of all 64.7% and of excessive drinkers 52.4% had never been asked about drinking. Of all 6.0% and of excessive drinkers 19.0% were advised about alcohol drinking at the consultation in question. Conclusion: Alcohol drinking is rarely brought up in discussion by primary health care professionals, even in the case of excessive drinkers.

Anabolic steroids: A review for the clinician.

Kutscher EC; Lund BC; Perry PJ. Sports Medicine 32(5): 285-296, 2002. (54 refs.)
The number of athletes self-administering ergogenic pharmacological agents to increase their competitive edge continues to be a problem. Most athletes using anabolic steroids (AS) have acquired a crude pharmacological database regarding these drugs. Their opinions regarding steroids have been derived from their subjective experiences and anecdotal information. For this reason, traditional warnings regarding the lack of efficacy and potential dangers of steroid misuse are disregarded. A common widely held opinion among bodybuilders is that the anabolic steroid experts are the athletic gurus who for years have utilised themselves as the experimental participants and then dispensed their empirical findings. This review will address the common anabolic steroid misconceptions held by many of today's athletes by providing an evaluation of the scientific literature related to AS in athletic performance.

Alcohol, breastfeeding, and development at 18 months.

Little RE; Northstone K; Golding J. Pediatrics 109(5): NIL_9-NIL_14, 2002. (14 refs.)
Objective. We aimed to replicate a previous study of 1-year-olds that reported a deficit in motor development associated with moderate alcohol use during lactation, using a different but comparable population. Methodology. The mental development of 915 18-month-old toddlers from a random sample of a longitudinal population-based study in the United Kingdom was measured using the Griffiths Developmental Scales. Frequent self-administered questionnaires during and after pregnancy provided maternal data. The dose of alcohol available to the lactating infant was obtained by multiplying the alcohol intake of the mother by the proportion of breast milk in the infant's diet. We compared this dose with the Griffiths Scales of Mental Development, taking into account potentially confounding variables. Result. Three of the Griffiths scales increased slightly but significantly with increasing infant alcohol exposure; there was no association in the remaining 2 or average of the scales. Discussion. We were unable to replicate the earlier deficit in motor skills associated with lactation alcohol use. One reason may be that the tests dose of alcohol reaching the lactating infant is small, and infants and toddlers have limited ability to pick up small effects. Studies of older children may resolve the question of the safety of drinking while nursing.

Treatment of heroin dependence with buprenorphine in primary care.

Fiellin DA; Pantalon MV; Pakes JP; O'Connor PG; Chawarski M; Schottenfeld RS. American Journal of Drug and Alcohol Abuse 28(2): 231-241, 2002. (27 refs.)
Buprenorphine is an effective treatment for heroin dependence. The feasibility and potential efficacy of buprenorphine with brief counseling in primary care is unknown. We enrolled 14 heroin dependent patients in a 13-week clinical trial using thrice weekly buprenorphine along with brief counseling in the primary care center of an urban medical center. Primary outcomes included urine toxicology and treatment retention. Opioid-positive urine toxicology tests reduced over the 13-week period from 95 to 25% (p < 0.05). Eleven patients (79%) had greater than or equal to one week of opioid-free urine toxicologies. Nine patients (64%) had greater than or equal to three weeks of opioid-free urine toxicologies. Eleven patients (79%) were retained through the maintenance phase. We conclude that buprenorphine maintenance is feasible in a primary care setting.

Excess alcohol consumption and health outcomes: A 6-year follow-up of men over age 50 from the Health and Retirement Study.

Perreira KM; Sloan FA. Addiction 97(3): 301-310, 2002. (50 refs.)
Aims This study examined the association of problem drinking history and alcohol consumption with the onset of several health conditions and death over a 6-year follow-up period. Setting We analyzed two waves of longitudinal data on men over 50 who participated in the Health and Retirement Study, a nationally representative sample of people aged 51-61 and their spouses living in the United States in 1992. Measurements Five types of health outcomes-mortality. general health, functional status. cognitive status, and mental health-were examined. Drinking categories were based on average drinks per day (0, <1, 1-2, 3-4, 5+) with 5 + defined as 'very heavy drinking'. Problem drinking history was identified as 2+ affirmative responses to the CAGE questionnaire. We controlled for smoking and other factors at baseline. Findings Over the 6-year follow-up period. very heavy drinking at baseline quadrupled the risk of developing functional impairments (OR: 4.21 95% CI: 1.67. 10.61). A problem drinking history increased the onset of depression (OR: 1.67 95%, CI: 1.02, 2.74), psychiatric problems (OR: 2.15 95% CI: 1.47. 3.13) and memory problems (OR: 1.71 95%. CI: 1.14, 2.56). Heavy drinking among mature adults was not associated with increased incidence of other adverse health events (i.e. angina, cancer, congestive heart failure, diabetes, myocardial infraction, lung disease or stroke). Conclusion: Very heavy drinking and a problem drinking history greatly increased rates of onset of functional impairments, psychiatric problems and memory loss in late middle age for men who had not experienced these impairments at their initial interview.

Smoking cessation.

(review).
Karnath B. American Journal of Medicine 112(5): 399-405, 2002. (61 refs.)
Smoking is a risk factor for the four leading causes of death in the United States, yet 48 million Americans-24% of the U.S. adult population-continue to smoke. Approximately 70% of people who smoke visit a physician each year, yet only half report ever being advised to quit smoking by their physician. Smoking cessation is difficult due to nicotine addiction and withdrawal symptoms. Expert groups such as the National Cancer Institute and the Agency for Health Care Policy and Research offer protocols for smoking cessation that primary care physicians can use in their office practice. Recent developments in the pharmacotherapy of smoking cessation has led the U.S. Public Health Service to update the practice guidelines for treating tobacco use and dependence. Pharmacotherapy, which includes nicotine replacement therapy, offers assistance to patients who want to stop smoking. However, the cost of pharmaco-therapy may be a barrier for some. Other nonpharmacologic therapies, such as counseling, are also effective.

...on Substance use in Primary Care