CORK Newsletter Primary Care Winter 2002

powerpoint presentations
CORK database search
resource materials
bibliographies
clinical tools
user services
newsletters
about cork
home

...on Substance Abuse and Primary Care

www.ProjectCork.org

Winter 2002/03

Domestic violence compared to other health risks: A survey of physicians' beliefs and behaviors.

Gerbert B; Gansky SA; Tang JW; McPhee SJ; Carlton R; Herzig K et al. American Journal of Preventive Medicine 23(2): 82-90, 2002. (57 refs)
Background: Physicians routinely confront patient risk behaviors once considered private, including tobacco use, alcohol abuse, and HIV/STD- risk behavior. We compared physicians behaviors and beliefs on screening and intervention for domestic violence with each other risk. Methods: Survey of nationwide, random sample of 610 primary care physicians from the American Medical Association Physician Masterfile. Results: Fewer primary care physicians screened for domestic violence than for other risks (p < 0.001) once domestic violence was identified, however, physicians intervened with equal or greater frequency than for other risks. Fewer believed that they knew how to screen or intervene for domestic violence compared with other risks, and significantly fewer believed that domestic violence interventions were successful compared with interventions for tobacco and HIV/STD risks (Bonferroni adjusted p < 0.001). Conclusions: Lower domestic violence screening rates may reflect physicians' beliefs that they do not know how to screen or intervene, and that interventions are less successful for domestic violence than for other risks. We may improve screening rates by educating physicians that a simplified role, as for other risks, can be effective for domestic violence.

Effectiveness of a clinic-based strategy for implementing the AHRQ Smoking Cessation Guideline in primary care.

Katz DA; Muehlenbruch DR; Brown RB; Fiore MC; Baker TB. Preventive Medicine 35(3): 293-302, 2002. (35 refs)
Background. The Agency for Healthcare Research and Quality Smoking Cessation Practice Guideline recommends systematic assessment of smoking status and counseling of smokers at every visit, but the actual effectiveness of the guideline in primary care practice is unknown. Methods. We conducted a nonrandomized, controlled before-after trial of a guideline-derived intervention that includes routine identification and brief counseling of smokers by nurses and medical assistants, coupled with free nicotine replacement therapy (NRT) and telephone counseling of those smokers who are willing to make a quit attempt, and feedback on performance of guideline-recommended activities. The intervention was pilot tested at I family practice (FP) clinic over a 2-month period; patterns of usual care were observed concurrently at four control FP clinics. We obtained exit interviews of 651 consecutive adult smokers who presented for routine, nonemergency care. Abstinence (7-day point prevalence) was determined by telephone interview during 6-month follow-up. Results. Concordance with guidelines was significantly greater for all recommended actions at the test site during the intervention versus baseline (P less than or equal to 0.05). Significantly more intervention versus baseline patients at the test site reported abstinence at 2-month follow-up (21 vs. 4%, P = 0.0004), and more patients tended to be abstinent at 6-month follow-up (21 vs. 11%, P = 0.08). No significant differences in 2- or 6-month quit rates between intervention and baseline patients were observed at the control sites. Conclusions. Implementation of a guideline-driven smoking cessation intervention that focuses primarily on smokers who are interested in making a quit attempt is associated with increased abstinence in primary care practice.

Foster-placed and adopted children exposed in utero to opiates and other substances: Prediction and outcome at four and a half years.

Moe V. Journal of Developmental and Behavioral Pediatrics 23(5): 330-339, 2002. (54 refs)
This article presents a Norwegian prospective, longitudinal study of children prenatally exposed to opiates and other substances under conditions of minimal postnatal social risk. Outcome at 4 1/2 years of age is presented. The study reports on the prediction of later intellectual performance, on the basis of the children's prenatal, perinatal, and early developmental status, as well as the foster or adoptive parents' socioeconomic level. Significant differences were found between the substance-exposed group and the comparison group on the Bayley Scales at age 1 year and on the McCarthy Scales at age 4 1/2 years. The findings showed that although the mean cognitive scores were within normal limits at age 4 1/2 years, a special weakness in the area of visual-motor and perceptual abilities was detected among the substance-exposed children. It is indicated that these areas of performance are especially sensitive to the effect of prenatal adversity. A special vulnerability among the substance- exposed boys, detected at an earlier age, persisted at 4 1/2 years. The study indicates that even if children experience adequate caregiving, the accumulation of biomedical risk factors associated with prenatal substance exposure is still a potential determinant of developmental problems, especially in the area of perceptual-performance functions. The study also hints at differential influences of biomedical and environmental variables on outcome at age 4 1/2 years.

Gambling: An addictive behavior with health and primary care implications. (review).

Potenza MN; Fiellin DA; Heninger GR; Rounsaville BJ; Mazure CM. Journal of General Internal Medicine 17(9): 721-732, 2002. (102 refs)
Over the past several decades, and particularly during the last 10 to 15 years, there has been a rapid increase in the accessibility of legalized gambling in the United States and other parts of the world. Few studies have systematically explored the relationships between patterns of gambling and health status. Existing data support the notion that some gambling behaviors, particularly problem and pathological gambling, are associated with nongambling health problems. The purpose of this article is to provide a perspective on the relationship between gambling behaviors and substance use disorders, review the data regarding health associations and screening and treatment options for problem and pathological gambling, and suggest a role for generalist physicians in assessing problem and pathological gambling. A rationale for conceptualization of pathological gambling as an addictive disorder and a model proposing stress as a possible mediating factor in the relationship between gambling and health status are presented. More research is needed to investigate directly the biological and health correlates associated with specific types of gambling behaviors and to define the role for generalist physicians in the prevention and treatment of problem and pathological gambling.

Managed care plans' requirements for screening for alcohol, drug, and mental health problems in primary care.

Garnick DW; Horgan CM; Merrick EL; Hodgkin D; Faulkner D; Bryson S. American Journal of Managed Care 8(10): 879-888, 2002. (43 refs)
Objective: To determine managed care organizations' (MCOs) requirements for screening for alcohol, drug, or mental health problems in primary care settings. Study Design: A telephone survey was used to gather information on the 3 largest commercial products offered by MCOs. Products included health maintenance organizations, preferred provider organizations, and point-of-service plans. Methods: Managed care organizations were asked whether their products required screening for alcohol, drug, or mental health problems in primary care settings. Chi-square tests were performed to ascertain whether screening requirements, the distribution of practice guidelines, and the topics addressed in those guidelines varied by product type and contracting with specialty behavioral health vendors. The data were weighted to produce national estimates. Results: Only 14.9% of the products surveyed required any alcohol, drug, or mental health screening by primary care practitioners. Slightly more than half of all the products surveyed distributed practice guidelines that addressed mental illness, and about one third distributed substance abuse practice guidelines. Conclusions: Although the feasibility, utility, and effectiveness of screening are increasingly recognized, few MCOs currently require alcohol, drug, or mental health screening by primary care physicians in any of their product types.

Motivating parents of kids with asthma to quit smoking: The PAQS project.

Borrelli B; McQuaid EL; Becker B; Hammond K; Papandonatos G; Fritz G et al. Health Education Research 17(5): 659-669, 2002. (31 refs)
The Parents of Asthmatics Quit Smoking (PAQS) project contrasts two theory-based smoking cessation interventions for parents of children with asthma, and compares mechanisms of behavior change within and across theoretical perspectives. We hypothesize that enhancing the perception of risk to self and child will motivate smoking cessation more than standard approaches that emphasize building self-efficacy and coping skills for quitting in a population that is largely not motivated to quit smoking. Smokers (n = 288) and their asthmatic children who receive nurse-delivered in-home asthma education (as part of the insurance carrier's standard of care) are randomized into one of two treatment conditions: (1) the Behavioral Action Model (BAM), in which nurses emphasize goal setting and skill building to enhance self-efficacy to quit smoking, or 2) the Precaution Adoption Model (PAM), in which nurses tailor the intervention to the smoker's readiness to quit and incorporate biomarker feedback [i.e. level of carbon monoxide exposure to the smoker and level of environmental tobacco smoke (ETS) exposure to the child] in order to increase risk perception in smokers. In both conditions, smokers who are ready to quit receive the nicotine patch. Analyses will examine (1) quit rates, ETS level and motivation to quit as the primary dependent variables, (2) mediators of behavior change between and within conditions, and (3) relations between parent smoking outcomes and child asthma morbidity (i.e. ER visits and asthma symptoms) post-treatment. Results will help tailor interventions to this population, and identify mechanisms of behavior change that result in adaptive health outcomes for smokers and their children who have asthma.

One last pleasure? Alcohol use among elderly people in nursing homes.

Klein WC; Jess C. Health & Social Work 27(3): 193-203, 2002. (33 refs)
The study discussed in this article describes the alcohol-related policies, practices, and problems experienced by a sample of 111 intermediate care facilities and homes for elderly people. Data were collected using a semi-structured telephone interview and indicate that alcohol use and associated problems among nursing home residents are common. Despite the problems reported, screening for alcohol problems among residents, treatment of identified problems, and training of staff were not found to be widespread. Ambiguity about the role of alcohol as a social beverage or as a psychoactive substance to be managed was identified. Challenges to social workers and social work education are identified.

Women's reports of smoking cessation advice during reproductive health visits and subsequent smoking cessation.

Pollak KI; McBride CM; Scholes D; Grothaus LC; Civic D; Curry SJ. American Journal of Managed Care 8(10): 837-844, 2002. (46 refs)
Objective: To examine associations of women's characteristics with reports of provider advice to quit smoking and smoking cessation 1 year after a reproductive health visit. Study Design: Prospective survey. Methods: As part of a randomized smoking cessation trial, 432 women smokers completed telephone surveys 1 month and 1 year after their reproductive health visit. Most women were white (85%) with a mean age of 36 years. Results: Women more likely to report their provider advised them to, quit smoking were white rather than another race (adjusted risk ratio, [RR] = 1.4, confidence interval [CI] = 1.14-1.64), employed versus unemployed (RR = 1.3, CI = 1.041.49), engaged in safer versus riskier sexual practices (RR = 1.3, Cl = 1.04-1.54), were more rather than less ready to quit (RR = 1.3, Cl = 1.08-1.44), and saw family physicians versus gynecologists (RR = 1.3, CI = 1.12-1.41). Reported provider advice to quit smoking was not associated with subsequent cessation. Women were more likely to have quit smoking by the 1-year follow-up if at baseline they reported an annual Papanicolaou test in the prior 3 years (RR = 1.6, CI = 1.02-2.26), were more rather than less ready to quit smoking (RR = 2.0, CI = 1.36-2.62), and were less rather than more dependent on nicotine (RR = 0.7, CI = 0.59-0.84). Conclusions: Provider advice to quit is being directed to women who are most likely to quit and contributes little in explaining subsequent cessation. Providers may not be giving enough cessation advice to minority women, those not considering cessation, and those not prevention oriented. Interventions and system improvements are needed to increase providers' counseling of smokers who are unmotivated and from racial/ethnic minorities.

Patient compliance and maternal/infant outcomes in pregnant drug-using women.

Jones HE; Svikis DS; Tran G. Substance Use & Misuse 37(11): 1411-1422, 2002. (21 refs)
Treatment compliance is an important variable in drug use intervention. For pregnant drug-misusing women, compliance with treatment has been particularly problematic, even in specialized and more intensive treatment programs. The present study, conducted from March 1999 to June 2000, compared maternal/infant outcomes in pregnant drug-using women who were either compliant or noncompliant with drug use interventions offered through a prenatal care clinic. Compliant women (N = 11) completed four therapy sessions (behavioral reinforcement of drug abstinence+brief motivational therapy), while noncompliant women (N=20) participated in zero to three therapy sessions. The two groups were similar on demographic and drug use severity measures. Compliant mothers, however, gave birth to infants with higher birthweights than noncompliant mothers. Over half of compliant mothers were also drug-free at delivery, compared to one-fourth of noncompliant mothers. These data support an association between treatment compliance and birth outcomes, and highlight the need to develop strategies for improving compliance with such interventions.

Physician smoking-cessation actions: Are they dependent on insurance coverage or on patients?

Solberg LI; Davidson G; Alesci NL; Boyle RG; Magnan S. American Journal of Preventive Medicine 23(3): 160-165, 2002. (30 refs)
Background: Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5A's. Methods: A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit. Results: There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both. Conclusion: Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.

Treatment of heroin (diamorphine) addiction: Current approaches and future prospects. (review).

Gonzalez G; Oliveto A; Kosten TR. Drugs 62(9): 1331-1343, 2002. (104 refs)
New pharmacological treatments for heroin (diamorphine) addiction include drugs that reduce opiate withdrawal symptoms and agents that are given during the maintenance phase of treatment. A variety of different types of pharmacological agents (opioid agonists, partial opioid agonists, opioid antagonists and alpha(2)-adrenoreceptor agonists) are reviewed and the evidence of their use during managed withdrawal and maintenance are presented. Experimental approaches attempting to reduce the time of opiate withdrawal and to accelerate the transition to abstinence are being developed. The combination tablet of buprenorphine and naloxone that is to be introduced for office-based maintenance is currently undergoing intense evaluation in the US. This new approach may facilitate the expansion of treatment while reducing the potential for medication diversion and intravenous use. The use of heroin continues to increase and is estimated that eight million people in the world (0.14%) abuse opiates. The regions with the highest annual prevalence (2%) are South East and South West Asia, and based on the National Household Survey, the annual prevalence of heroin use in the US is 0.3% with a rising trend of heroin use in the last 2 years. Comprehensive treatments for heroin dependence include environmental changes. psychosocial interventions and pharmacotherapy. Recent advances in pharmacotherapy are aimed at reducing problems associated with persistent heroin use and expanding the accessibility of long- term treatment. For example, the introduction of the combination tablet of buprenorphine and naloxone into drug abuse treatment in an office-based setting should expand available treatment slots and facilitate general medical care of individuals who are addicted. This review focuses on the rationale, indications and limitations of medications that either facilitate the reduction of withdrawal symptoms during detoxification or improve the overall psychosocial stabilisation during maintenance, and briefly discusses potential future directions for opiate dependence treatments.

Problem substance use among depressed patients in managed primary care.

Roeloffs CA; Wells KB; Ziedonis D; Tang LQ; Unutzer J. Psychosomatics 43(5): 405-412, 2002. (37 refs)
This study identifies characteristics associated with problem substance use among 1,187 patients with either depressive symptoms (44%) or depressive disorders (56%) in primary care clinics of six managed care organizations. Sedative misuse (reported by 14% of all patients) was associated with greater wealth, social phobia, and misuse of prescription opioids. Cannabis use (11%) was associated with younger age, male gender single marital status, white ethnicity, less education, recurrent depression, agoraphobia, and hazardous alcohol use. Hazardous drinking (11%) was significantly associated with younger age, male gender, single marital status, and cannabis use. Greater understanding of substance use problems in primary care patients with depressive symptoms and disorders may aid efforts to more quickly identify, educate, and provide services for those in need.

Screening and brief intervention for excessive alcohol use: Qualitative interview study of the experiences of general practitioners.

Beich A; Gannik D; Malterud K. British Medical Journal 325(7369): 870-872B, 2002. (22 refs)
Objective: To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice. Design Qualitative interviews with general practitioners who had participated in a pragmatic study of a combined programme of screening and a brief intervention for excessive alcohol use. Doctors were interviewed either individually or in focus groups. A computer based, descriptive, phenomenological method was used to directly analyse the digitally recorded interviews. Setting and participants 24 of 39 general practitioners in four Danish counties who volunteered to take part in the pragmatic study were interviewed. Results The doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on the screening and to ensure compliance with die intervention. Although the doctors considered the doctor-patient relationship robust enough to sustain targeting of alcohol use, they often failed to follow up on initial interventions, and some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues. The doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviour. The programme needed considerable resources, and it interrupted the natural course of consultations and was inflexible. The doctors could not recommend the screening and brief intervention programme, although they thought it important to counsel their patients on drinking. Conclusions: Screening for excessive alcohol use created more problems than it solved for the participating doctors. The results underline the value of carrying out pragmatic studies on the suitability of seemingly efficacious healthcare programmes.

Parental smoking cessation and adolescent smoking.

Chassin L; Presson C; Rose J; Sherman SJ; Prost J. Journal of Pediatric Psychology 27(6): 485-496, 2002. (27 refs)
Objective: To examine the relation of parent smoking cessation to adolescent smoking and test its potential mediators. Method: Participants were 446 adolescents and their parents who completed a computerized measure of implicit attitudes toward smoking and questionnaires assessing smoking, parenting, and explicit attitudes. Results: Parental smoking cessation was associated with less adolescent smoking, except when the other parent currently smoked. In general, ex-smoking parents showed more antismoking socialization than did smoking parents. However, in children's reports, these effects were negated if the other parent (particularly the mother) smoked. Children's reports of parents' antismoking behavior partially mediated the relation between parental smoking and adolescent smoking. Although children's implicit and explicit attitudes were unrelated to parental smoking, mothers' implicit attitudes were related to both their own smoking and their child's smoking. Conclusions: Parental smoking cessation may help lower risk for adolescent smoking. However, this benefit may be realized only if the other parent does not currently smoke. Antismoking parenting might be a useful focus in cessation interventions.

Substance use-related outpatient consultations in specialized health care: An underestimated entity.

Sillanaukee P; Kaariainen J; Sillanaukee P; Poutanen P; Seppa K. Alcoholism: Clinical and Experimental Research 26(9): 1359-1364, 2002. (32 refs)
Background: To study the occurrence and documentation of substance use related outpatient visits in, specialized health care. Methods: The diagnosis recorded in retrospective discharge data in Tampere University Hospital for 6 years was compared with the prospective data gathered from separately completed forms added during an 8-week period to every outpatient's discharge data. In this form, the relation of substance use and the actual reason for the consultation were specifically elicited. Results: On the basis of diagnoses, retrospectively, 0.4% (6,666 of 1,555,898) of outpatient visits were caused by substance use: In the prospective part of the study, 5.6% of visits (1,401/25,014) were related to substance use. Retrospective study demonstrated 2% prevalence of substance use, whereas prospective study showed 36% substance use-related visits at the emergency room. According to the retrospective discharge data, alcohol-related organ damages were the major reason for substance use-related outpatient visits. In the prospective study, the proportion of acute traumas was most prevalent. Conclusions: Our study indicates that substance use-related visits often remain undetected in specialized health care. Substance use-related visits were under documented/undetected in the emergency room. Using a simple separate form could dramatically increase the detection of substance use-related visits.

Screening for health behaviors in ambulatory clinical settings: Does smoking status predict hazardous drinking?

Kranzler HR; Amin H; Cooney NL; Cooney JL; Burleson JA; Petry N; Oncken C. Addictive Behaviors 27(5): 737-749, 2002. (33 refs)
Although a link between alcohol consumption and smoking behavior is well documented, the majority of studies have focused on individuals dependent on both alcohol and nicotine. The present study examined the likelihood of hazardous drinking as a function of smoking status, gender, age, ethnicity, and education in a sample of 676 medical and dental patients whose drinking covered the spectrum from abstinence to high levels. We hypothesized that hazardous drinking would be more common among young, male respondents who were current smokers and that past smokers would show a risk of hazardous drinking that was intermediate between that of current smokers and nonsmokers. Results showed that younger age, fewer years of education, male gender, and current smoking status were significant predictors of hazardous drinking. However, there was no relationship between a past history of smoking and current risk of hazardous drinking. Evaluation of the Fagerstrom Tolerance Questionnaire (FTQ) showed that it was no more useful as a screening instrument than a single question that elicited current smoking status. These findings suggest that patients who report current smoking should routinely be asked about their current alcohol consumption. Interventions should then be tailored to address smoking and, if appropriate, hazardous drinking as well.

The Alcohol Use Disorders Identification Test (AUDIT) predicts alcohol withdrawal symptoms during inpatient detoxification.

Reoux JP; Malte CA; Kivlahan DR; Saxon AJ. Journal of Addictive Diseases 21(4): 81-91, 2002
We evaluated whether the Alcohol Use Disorders Identification Test (AUDIT) predicted clinically meaningful alcohol withdrawal syndrome (AWS) in 118 alcohol dependent patients without a history of seizures. Patients were monitored by serial administration of the revised Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar) during inpatient detoxification. Patients (N = 55) who reached threshold level of AWS for receiving medication (CIWA-Ar greater than 9) scored significantly higher (p < .001) on the AUDIT total score, the dependence sub-scale, and the single item on morning drinking.. Sensitivity, specificity, positive and negative predictive power, and screening efficiency showed the value of the AUDIT for identifying patients who developed AWS. The AUDIT should be explored alone and in combination with other parameters to improve screening for clinically meaningful AWS in other settings.