Library Watch: Primary Care

Serving Substance Abuse Professionals Since 1993

Last Update: 06.03.04

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...on Substance Abuse and Primary Care

www.ProjectCork.org

Spring 2004

Investigation of systems to prevent diversion of opiate drugs in general practice in the UK.

Baker R; Moss P; Upton D; Pankhania J. Quality & Safety in Health Care 13(1): 21-25, 2004. (13 refs.)
Background: Statutory regulations govern the procedures that must be followed by general practitioners (GPs) in the UK to minimise the risk of diversion of prescribed opiate drugs for illicit use. However, evidence presented at the trial of Harold Shipman, a GP convicted of murdering patients with diamorphine, suggests that the regulations and monitoring of GPs' prescribing are failing. Aim: To assess the policies followed by general practices in Leicestershire and Rutland with regard to the controlled drugs regulations. Methods: A semi-structured interview was administered to a purposeful sample of lead GPs to explore how their practices applied the regulations. The controlled drugs registers and drug storage facilities in these practices were inspected. A questionnaire was sent to all the remaining practices to seek information about their application of the regulations, any concerns they had about the regulations, and any suggestions for improving them. Results: Of the 142 general practices in Leicestershire, the lead GP in 14 took part in the interviews. Respondents expressed dissatisfaction with current policies including the design of controlled drug registers, and generally supported the reintroduction of an inspection scheme. Ninety (70.9%) of the 127 practices to whom the questionnaire was sent responded and, of these, 31 (34.4%) no longer held a supply of controlled drugs. Those that did hold controlled drugs indicated concern about the regulations, confusion about some aspects including the return and disposal of unused drugs, and a desire for advice and support in the implementation of the regulations. Forty two of the 59 respondents who held a supply of controlled drugs (71.2%) would welcome regular inspection. Conclusion: GPs are confused about the controlled drugs regulations and have little support in implementing them. The suspension of inspection schemes has reduced the amount of advice and support available to them and, in consequence, the regulations are interpreted differently in different practices. These findings are cause for concern about the risk of diversion of controlled drugs, and illustrate how patient safety systems can decay when they are not maintained.

Is substance abuse a medical problem?

Jonas S. Addictive Disorders & Their Treatment 2(4): 123-133, 2003. (38 refs.)
Abuse of psychoactive drugs for non-medicinal purposes--termed "substance abuse"--is a medical problem, a major one. Like many other major medical problems--heart disease, cancer, diabetes, obesity, sedentary lifestyle--it also has behavioral, social, economic, and political dimensions. However, any consideration of substance abuse differs significantly from the consideration of the problems in the list above, for the following reasons. First, national legal policy, beyond conventional health care system policy, has a singular role in determining how the United States deals with the problem. Second, national legal policy is central to any consideration of how substance abuse is dealt with in the United States. This phenomenon is a direct result of how the substance abuse problem and its several components are defined, politically and legislatively. Neither medicine nor other science underlie this peculiar definition. The centrality of definitions to the understanding of the substance abuse problem and how it is dealt with makes it unique among the major medical problems. The fact that substance abuse is the only medical problem defined primarily in the political and legislative arenas rather than the medical and scientific ones has an enormous impact on national policy-making.

Medical specialization, profession, and mediating beliefs that predict stated likelihood of alcohol screening and brief intervention: Targeting educational interventions.

Gassman RA. Substance Abuse 24(3): 141-156, 2003. (70 refs.)
Practitioner-level educational approaches that promote screening and brief intervention (SBI) seldom consider providers' profession and medical specialization. Strategies that consider these variables may be better equipped to affect change in beliefs and behavior. The aim of this study was to identify beliefs that predict stated likelihood of practicing SBI by specialty and health profession in order to guide the direction of educational strategies. Physicians and nurse practitioners were studied that specialized in family, internal, obstetric gynecology (ObGyn), and pediatric medicine. The results indicated that independent of amount of previous postgraduate alcohol education and knowledge, self-rated competence mediated between specialty and likelihood of practicing SBI. For instance, low self-rated competence for ObGyn was a barrier that suppressed likelihood of practicing SBI. Other findings were that role legitimacy mediated the association between profession and likelihood of SBI, so that lack of role legitimacy was a barrier for physicians but not for nurse practitioners. We suggest that targeted educational strategies for ObGyn and pediatric clinicians may prove more effective than the prevalent one-size-fits all approaches aimed at general adult populations.

Motivating and helping smokers to stop smoking.

Hughes JR. Journal of General Internal Medicine 18(12): 1053-1057, 2003. (27 refs.)
Smokers try to quit only once every 2 to 3 years and most do not use proven treatments. Repeated, brief, diplomatic advice increases quit rates. Such advice should include a clear request to quit, reinforcing personal risks of smoking and their reversibility, offering solutions to barriers to quitting, and offering treatment. All smokers should be encouraged to use both medications and counseling. Scientifically proven, first-line medications are nicotine gum, inhaler, lozenge, and patch plus the nonnicotine medication bupropion. Proven second-line medications are clonidine, nicotine nasal spray, and nortriptyline. These medications are equally effective and safe and the incidence of dependence is very small. The proven psychosocial therapies are behavioral and supportive therapies. These are as effective as medications and are effective via individual counseling, group, and telephone formats.

Pediatrician self-efficacy for counseling parents of asthmatic children to quit smoking.

Cabana MD; Rand C; Slish K; Nan B; Davis MM; Clark N. Pediatrics 113(1): 78-81, 2004. (14 refs.)
Background. Although environmental tobacco smoke is a common trigger for asthma exacerbations in children, pediatricians infrequently counsel parents who smoke to quit. High physician self-efficacy, or self-confidence, in the ability to counsel parents about smoking cessation is associated with increased physician screening and counseling on this topic. However, it is not clear which factors are associated with high physician self-efficacy for counseling, such as previous training in smoking-cessation counseling or number of years in pediatric practice. Objective. To identify factors associated with high levels of physician self-efficacy for 4 skills associated with smoking-cessation counseling. Design. Cross-sectional survey. Participants. A national random sample of 829 primary care pediatricians. Results. The response rate was 55% (457 of 829). The percentage of physicians with high levels of self-efficacy for screening parents and screening patients to identify smokers was 87% and 84%, respectively. The percentage of physicians with high levels of self-efficacy for counseling parents and patients was 59% for both groups. The presence of previous training in smoking-cessation counseling was associated with high levels of self-efficacy for all 4 skills including inquiring about an asthma patient's smoking status (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.63, 9.37); inquiring about a parent's smoking status (OR: 2.51; 95% CI: 1.09, 5.75); counseling a patient to quit smoking (OR: 5.30; 95% CI: 3.02, 9.31); and counseling a parent to quit (OR: 4.96; 95% CI: 2.85, 8.61). Years since completion of residency were not associated with high self-efficacy. Conclusions. These findings suggest that formal training in smoking cessation has a significant impact on physician self-efficacy related to smoking cessation throughout a physician's career.

Physician and enrollee knowledge of Medicaid coverage for tobacco dependence treatments.

McMenamin SB; Halpin HA; Ibrahim JK; Orleans CT. American Journal of Preventive Medicine 26(2): 99-104, 2004. (8 refs.)
Background: The 2000 Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommends health insurance coverage for tobacco-dependence treatments proven effective in helping smokers to quit. Two states with comprehensive coverage for tobacco-dependence treatments in their Medicaid programs were selected to document awareness of coverage for tobacco-dependence treatments among primary care physicians who treat Medicaid enrollees and Medicaid-enrolled smokers. Methods: In 2000, surveys were conducted among Medicaid smokers (n =400) and physicians (n =160) to document knowledge of covered tobacco-dependence treatments under state Medicaid programs in two states with comprehensive coverage. Results: Only 36% of Medicaid-enrolled smokers and 60% of Medicaid physicians knew that their state Medicaid program offered any coverage for tobacco-dependence treatments. Physicians were more than twice as likely to know that pharmacotherapies were covered compared to counseling. Conclusions: Greater effort is needed to make Medicaid smokers and physicians aware that effective pharmacotherapies and counseling services are available to assist in treating tobacco dependence. Additionally, future research should explore the methods that are most effective in informing patients and providers regarding covered-benefits.

Screening in brief intervention trials targeting excessive drinkers in general practice: Systematic review and meta-analysis.

Beich A; Thorsen T; Rollnick S. British Medical Journal 327(7414): 1-7, 2003. (50 refs.)
The purpose of this research was to determine the effectiveness of programmes of screening in general practice for excessive alcohol use and providing brief interventions. The study was a systematic review and meta-analysis of randomised controlled trials that used screening as a precursor to brief intervention. The main outcome measures were number needed to treat, proportion of patients positive on screening, proportion given brief interventions, and effect of screening. The 8 studies included for meta-analysis all used health questionnaires for screening, and the brief interventions included feedback, information, and advice. The studies contained several sources of bias that might lead to overestimates of the effects of intervention. Although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. This meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol.

Smoking cessation interventions in cardiovascular patients.

Wiggers LCW; Smets EMA; de Haes JCJM; Peters RJG; Legemate DA. European Journal of Vascular and Endovascular Surgery 26(5): 467-475, 2003. (71 refs.)
Objectives. To review current evidence for the effectiveness of smoking cessation interventions in cardiovascular patient populations. Design and materials. Studies were obtained from systematic reviews of the Cochrane Tobacco Addiction Review Group. Twelve Cochrane reviews related to secondary prevention in a variety of populations were used to extract eligible studies. Studies were eligible when they considered smokers diagnosed with symptomatic cardiovascular disease. Methods. Data concerning the comparison between the intervention of interest and a placebo or standard treatment group were derived from eligible papers. Based on these data, Absolute Risk Reduction figures were calculated to express the effectiveness of each intervention on smoking cessation. Results. We found 12 studies examining smoking cessation interventions in cardiovascular patients. Five studies reported significant results. No evidence was found for Nicotine Replacement Therapy or other pharmacology to be effective, neither for self-help materials, group, individual or telephone counseling. There is limited evidence for physician's advice and nurse delivered interventions to be effective. Conclusions. Smoking cessation studies in cardiovascular patients are scarce. The available studies show very limited effects. The reasons for the lack of success of smoking cessation strategies in these patients remain unclear. Further research is needed to find effective cessation strategies for patients with cardiovascular diseases.

Use of biomarkers of heavy drinking in health care practice.

Allen JP. Military Medicine 168(5): 364-367, 2003. (32 refs.)
Several biochemical tests are available to screen for heavy drinking in patients. Most of these (e.g., liver function tests and macrocytic volume) rise due to adverse effects of alcohol on organs or the organ's functions. Carbohydrate-deficient transferrin, however, seems to elevate because of the direct action of alcohol or one of its metabolites. A second valuable contribution of biomarkers is identification of relapse events in recovering alcoholics that either would not be voluntarily reported or reported only much later. Finally, providing feedback to patients in treatment based on their biomarker values and changes in them during the course of treatment can enhance motivation, a key component in recovery from alcohol problems. The current article offers a clinical rationale for routine use of biomarkers of heavy drinking in health care practice and proposes recommendations on how they might be best used.

Brief interventions for hazardous drinkers delivered in primary care are equally effective in men and women.

Ballesteros J; Gonzalez-Pinto A; Querejeta I; Arino J. Addiction 99(1): 103-108, 2004. (24 refs.)
Background: Despite the accumulated evidence on the efficacy of brief interventions in hazardous drinkers some ambiguity remains regarding their differential effectiveness by gender. Methods: Meta-analysis of independent studies conducted in primary health care settings with a follow-up of 6-12 months which report results separately by gender. Two outcome measures were selected: the quantity of typical weekly alcohol consumption and the frequency of drinkers who reported consumption below hazardous levels after the intervention. Results: Seven studies were included in the meta-analysis. The standardized effect sizes for the reduction of alcohol consumption were similar in men (d = 0.25; 95% CI = 0.34 to 0.17) and women (d = 0.26; 95% CI = 0.38 to 0.13). The odds ratios (OR) for the frequency of individuals who drank below harmful levels were also similar (four studies; OR for men = 2.32; 95% CI = 1.78-2.93; OR for women = 2.31; 95% CI = 1.60-3.17). The difference between genders was negligible. Conclusion: Our results support the equality of outcomes among men and women achieved by brief interventions for hazardous alcohol consumption in primary care settings.

Common problems in patients recovering from chemical dependency.

Jones EM; Knutson D; Haines D. American Family Physician 68(10): 1971-1978, 2003. (31 refs.)
Chemical dependency is a common, chronic disease that affects up to 25 percent of patients seen in primary care practices. The treatment goal for patients recovering from chemical dependency should be to avoid relapse. This requires physicians to have an open, nonjudgmental attitude and specific expertise about the implications of addiction for other health problems. First-line treatment for chemical dependency should be nonpharmacologic, but when medication is necessary, physicians should avoid drugs that have the potential for abuse or addiction. Medications that sedate or otherwise impair judgment also should be avoided in the. recovering patient. Psychiatric illnesses should be aggressively treated, because untreated symptoms increase the risk of relapse into chemical dependency. Selective serotonin reuptake inhibitors may help to lower alcohol consumption in depressed patients, and desipramine may help to facilitate abstinence in persons addicted to cocaine. If insomnia extends beyond the acute or postacute withdrawal period, trazodone may be an effective treatment. If nonpharmacologic management of pain is not possible, nonaddictive medications should be used. However, if nonaddictive medications fail, long-acting opiates used under strict supervision may be considered. Uncontrolled pain in itself is a relapse risk.

Hepatitis C infection among drug users attending general practice.

Cullen W; Bury G; Barry J; O'Kelly FD. Irish Journal of Medical Science 172(3): 123-127, 2003. (39 refs.)
Background: The prevalence of hepatitis C (HCV) infection among injection drug users is high and addiction-related care is increasingly being provided by GPs in Ireland. Aims: To determine the prevalence and associated factors of HCV infection among injecting drug users attending general practice. Methods The records of 571 patients attending 42 general practices in the Eastern Regional Health Authority (ERHA) area for methadone maintenance treatment were reviewed. Results The HCV status was recorded in 380 cases (67%). Of these, 193 had a test performed by their GP, 74 had been tested by another service and 113 had no evidence of being tested, but HCV status was recorded based on information provided by the patient himself. A total of 276 cases were identified as being HCV positive (prevalence 73%), with no difference in prevalence between the three sources of information (p=0.12). A history of injecting drug use was the major determinant of testing for HCV. Conclusions: While a large proportion of drug users attending GPs for methadone maintenance treatment are known to be HCV positive, a considerable number have not been tested. Barriers to testing need to be explored to facilitate comprehensive screening.

Reducing substance use among African American adolescents: Effectiveness of school-based health centers. Robinson WL; Harper GW; Schoeny ME. Clinical Psychology: Science and Practice 10(4): 491-504, 2003. (77 refs.)

This paper explores the impact of school-based heath centers (SBHCs) on the substance use behaviors of low-income, inner-city African American adolescents. Researchers surveyed 2,114 9th- and 11th-grade students from seven inner-city public high schools (three with SBHCs and four without SSHCs). Of the initial 2,114 students, 598 SBHC students and 598 non-SBHC students were successfully matched using ethnicity, grade, gender, and propensity scores. The results of separate grade x gender x SBHC ANOVAs indicated significant grade x SBHC interactions (i.e., such that substance use decreased in SBHC schools while increasing in non-SBHC schools) for cigarettes (p =.05) and marijuana (p <.001), but. not for alcohol. These findings show that the SBHC intervention model is promising toward the prevention and reduction of substance use among high-risk African American adolescents and highlight the importance of accessible, holistic, and culturally appropriate health care.

Evaluation of medical student attitudes toward Alcoholics Anonymous.

Fazzio L; Galanter M; Dermatis H; Levounis P. Substance Abuse 24(3): 175-185, 2003. (23 refs.)
This is a two-phase study on attitudes of medical students toward Alcoholics Anonymous. The first phase compares views of addiction faculty to third-year medical students on the importance of spirituality in addiction treatment. We administered a questionnaire to assess attitudes toward spiritual, biological, and psychosocial approaches to addiction treatment. The faculty viewed spirituality as relatively more important in addiction treatment than did the students. The second phase was designed to assess whether medical student attitudes toward spiritually based treatments changed over the course of a psychiatry clerkship. At the beginning of the clerkship, students rated a spiritually oriented approach as important in addiction treatment as a biological approach, whereas, at the end of the clerkship, they rated the biological approach as more important. It may be important to educate medical students about the spiritual dimensions of recovery so they can integrate this into their treatment of addiction.

Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement.

Winickoff JP; Buckley VJ; Palfrey JS; Perrin JM; Rigotti NA. Pediatrics 112(5): 1127-1133, 2003. (61 refs.)
Objective. To evaluate the feasibility of implementing a smoking cessation intervention for parents at the time of the pediatric visit. Methods. A prospective cohort of smoking parents whose child was seen in an outpatient pediatric practice was offered the Stop Tobacco Outreach Program, which includes 3 brief counseling sessions, written materials, free nicotine replacement therapy (NRT), proactive referral to a free state telephone quitline, and fax referral to the parents' primary clinician. The primary outcome was completion of all three counseling sessions. Other outcomes were quit attempts, cessation, NRT use, state quitline use, and household smoking assessed at 2-month follow-up. Results. One hundred fifty-eight smoking parents met eligibility criteria and 100 (63%) enrolled in the study. Of the 100 enrollees, 81% completed all three counseling sessions and 78% accepted free NRT at the time of enrollment. At 2-month follow-up, of the 100 enrollees, 56% reported making a quit attempt of >24 hours, 18% reported 7-day tobacco abstinence, 34% used NRT, and 42% received additional counseling from the state telephone quitline. The mean number of cigarettes smoked inside the home and car declined over 2 months (home, 5.1 vs 1.4; and car, 2.5 vs 1.4). Conclusions. This study demonstrates the feasibility of engaging parents in a smoking cessation intervention at the time of a child's clinic visit. This approach may be an effective way to reach smokers who otherwise are unlikely to access smoking cessation interventions. High rates of program enrollment, use of NRT, and completion of telephone counseling in this study support the hypothesis that a child's clinic visit is a teachable moment to address parental smoking cessation.