CORK Library Watch, Primary Care, Summer 2004

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...on Substance Abuse and Primary Care

www.ProjectCork.org

Summer 2004

Differences in brief interventions on excessive drinking and smoking by primary care physicians: Qualitative study.

Aira M; Kauhanen J; Larivaara P; Rautio P. Preventive Medicine 38(4): 473-478, 2004. (23 refs.)
Background. Brief interventions by primary care physicians have been shown to be effective in reducing both smoking and excessive drinking. However, physicians seem to target smoking more often than drinking. We aimed to explore this difference in health promotion practises for finding ways to improve alcohol interventions in primary health centres. Methods. Qualitative semistructured interviews of 35 physicians in four health centres in Finland, and triangulation by audit of notes made by these doctors concerning alcohol drinking and smoking in medical records (n = 1200) of randomly selected 20-60 years old patients, who had visited their physician at least once in a 12-month study period. Results. On the basis of the interviews, there were five main differences in preventive work between issues of alcohol use and smoking: recognition, perceived importance as a health risk factor, intervention tools available, stigmatising label, and expectations about the effectiveness of counselling. In 106 (8.8%) of medical records, there was a mention of smoking, and in 82 (6.8%) of alcohol use (P < 0,0001). Quantity of alcohol consumption was described obscurely. When one of the visits was made for hypertension, diabetes, dyspepsia, general health check or heart arrhythmias, smoking was recorded more often than alcohol consumption. Conclusions. Tobacco use was mentioned more often in medical records than alcohol drinking. Physicians were more comfortable in undertaking a preventive approach for smoking than for alcohol use. The factors contributing to this difference must be considered in any attempts to improve implementation of secondary prevention of alcohol misuse.

How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta-analysis.

Anderson P; Jane-Llopis E. Addiction 99(3): 299-312, 2004. (53 refs.)
Aims: A systematic review of studies testing the effectiveness of educational and practice base strategies to increase the involvement of primary health-care practitioners in the treatment of tobacco dependence. Data sources: MEDLINE, EMBASE, CINAHL and the Cochrane Library (1966-2001). Selection criteria included studies that used randomized or controlled clinical designs, controlled before and after trials and interrupted time-series designs and that presented objective and interpretable measures of practitioners' behaviour and biochemically verified patient quit rates. Review methods: A meta-analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies' sample sizes. Findings: Analyses to explain the heterogeneity of effect sizes found that interventions were equally effective in changing practitioners' screening and advice-giving rates and their patients' quit rates. Absolute increases for the intervention above the comparison groups were 15% (95% CI = 7-22) for screening rates, 13% (95% CI = 9-18) for advice-giving rates and 4.7% (95% CI = 2.5-6.9) for biochemically verified patient quit rates. Practitioners in training programmes were effective in changing their patients' quit rates but not their own screening rates; educational interventions were more effective than practice-based interventions. For established practitioners, programmes were effective in changing their screening and advice-giving rates, but not their patients' quit rates; a combination of practice-based and educational interventions were more effective. Conclusions: Primary health-care practitioners can be engaged in the treatment of tobacco dependence to increase equally their screening and advice-giving rates and their patients' quit rates with outcomes of considerable public health and clinical significance. The provision of educational interventions for practitioners in training in combination with systematic outreach practice-based support for established practitioners is likely to be an effective strategy to increase smoking quit rates throughout primary health care.

Engaging general practitioners in the management of hazardous and harmful alcohol consumption: Results of a meta-analysis.

Anderson P; Laurant M; Kaner E; Wensing M; Grol R. Journal of Studies on Alcohol 65(2): 191-199, 2004. (67 refs.)
Objective: A systematic review was undertaken of studies that test the effectiveness of different strategies used to increase general practitioners' rates of screening for and giving advice about hazardous and harmful alcohol consumption. Method: Resources were MEDLINE, EMBASE, Cinahl and the Cochrane Library (1966-2001). Inclusion criteria were those of the Effective Practice and Organisation of Care Group of the Cochrane Collaboration. A meta-analysis was undertaken. using a random effects model, of 15 programs identified in 12 trials. Effect sizes, calculated using the logged odds ratio, were adjusted by inverse variance weights to control for the sample sizes of the studies. Results: Analysis of the intervention groups resulted in screening and advice-giving rates of 45% (95% Cl: 33%-56%) and analysis of the comparison groups resulted in rates of 32% (95% Cl: 20%-43%). The weighted mean effect size (logged odds ratio = 0.73; 95% Cl: 0.56-0.90) was heterogeneous. Regression analysis to explain the heterogeneity found a significant effect for alcohol-specific programs compared with general prevention programs in which alcohol was included, and for multicomponent programs compared with single component programs. No significant differences were found between educational-based or office-based interventions. Conclusions: Although the small numbers of programs studied suggest caution be used in interpreting the results, it seems it is possible to increase the engagement of general practitioners in screening and giving advice for hazardous and harmful alcohol consumption. Although considerably more research of high quality is needed, promising programs are those that have a specific focus on alcohol and those that are multicomponent.

Efficacy of brief interventions for hazardous drinkers in primary care: Systematic review and meta-analyses. (review).

Ballesteros J; Duffy JC; Querejeta I; Arino J; Gonzalez-Pinto A. Alcoholism: Clinical and Experimental Research 28(4): 608-618, 2004. (80 refs.)
Background: Because recent research in primary care has challenged the findings of previous reviews on the efficacy of brief interventions (BIs) on hazardous drinkers, we conducted a systematic review and meta-analysis to update the evidence of bIs as applied in the primary care setting. Methods: We obtained source material by searching electronic databases and reference lists and hand-searching journals. We selected randomized trials providing frequency data that allowed assessment of the efficacy of BIs on an intention-to-treat basis. Results were summarized by the odds ratio (OR) of response. When appropriate, risk difference (RD) and its inverse (number needed to treat [NNT] to achieve a positive result) were also computed. Fixed and/or random effect models were fitted according to heterogeneity estimates. Results: Thirteen studies provided data for a dose-effect analysis, 12 for comparison of BIs with reference categories. No clear evidence of a dose-effect relationship was found. BIs outperformed minimal interventions and usual care (random effects model OR = 1.55, 95% confidence interval [CI] = 1.27-1.90; RD = 0.11, 95% CI = 0.06-0.16; NNT = 10, 95% CI = 7-17). Similar results were obtained when two influential studies were removed (fixed effect model OR = 1.57, 95% CI = 1.32-1.87; RD = 0.11, 95% CI = 0.07-0.15; NNT = 9, 95% CI = 7-15). The heterogeneity between individual estimates was accounted for by the type of hazardous drinkers (heavy versus moderate) and by the characteristics of the included individuals (treatment seekers versus nontreatment seekers). The funnel plot did not show evidence of publication bias. Conclusion: Our results, although indicating smaller effect sizes than previous meta-analyses, do support the moderate efficacy of bIs. Further research is outlined.

United Kingdom and United States healthcare providers' recommendations of abstinence versus controlled drinking.

Cox WM; Rosenberg H; Hodgins CHA; Macartney JI; Maurer KA. Alcohol and Alcoholism 39(2): 130-134, 2004. (17 refs.)
Aim: To assess whether selected characteristics of problem drinkers influence treatment goal recommendations - abstinence or controlled drinking - by healthcare providers in the UK and the US. Methods: Sixteen case-histories, composed with varying information regarding the clients' level of problem severity, degree of social support and sex, were read by 41 UK and 31 US healthcare providers, who then gave a recommendation of controlled drinking versus abstinence for each case on a seven-point Likert scale. Results: Overall, abstinence was recommended more strongly for higher-severity problem drinkers, those with higher social support (an unpredicted finding), and for female clients. Controlled drinking was more often recommended in the UK than in the US. However, the degree to which drinkers' problem severity, social support and sex each affected respondents' ratings depended on the level of one or more of the other variables and the country of the respondents. Conclusion: The degree to which healthcare providers recommend abstinence or controlled drinking as an outcome goal for problem drinkers varies according to both client characteristics and the country in which they work.

Processes of care during a randomized trial of office-based treatment of opioid dependence in primary care.

Fiellin DA; O'Connor PG; Chawarski M; Schottenfeld RS. American Journal on Addictions 13(Supplement 1): S67-S78, 2004. (28 refs.)
Improving office-based treatment of opioid dependence requires an evaluation of processes of care. We evaluated the care provided by physicians to opioid dependent patients during a trial of office-based methadone maintenance. We conducted chart audits and a focus group. Audits identified lapses in monitoring of urine toxicology results and paperwork completion. The focus group identified the logistics of dispensing, the receipt of urine toxicology results difficulties arranging psychiatric services, communications with the opioid treatment program, and non-adherence to medication as problematic. Strategies to support logistical aspects of office-based care should be developed. Chart audits and mentoring should be considered as a mechanism to foster quality care. These processes of care are likely to require attention for treatment using methadone or buprenorphine.

Integrating smoking cessation treatment into primary care: An effectiveness study.

Fiore MC; McCarthy DE; Jackson TC; Zehner ME; Jorenby DE; Mielke M et al. Preventive Medicine 38(4): 412-420, 2004. (34 refs.)
Background. Lack of interest has been cited as a reason not to offer cessation assistance to smokers, but research suggests that smokers accept treatments offered proactively. This study assessed acceptability, utilization, and effectiveness of free smoking cessation treatment among diverse primary care patients. Method. Medical assistants invited 4,174 adult smokers to participate. Enrollees (1,869) self-selected or were assigned to receive free nicotine patch therapy alone or in combination with the Committed Quitters((R)) program, and for some, individual counseling. Results. In nearly 68% of cases, patients accepted a treatment invitation; 77% of eligible smokers enrolled; 85% of these picked up free patches. Given a choice of treatments, 75% of participants elected a psychosocial treatment in addition to patch therapy. Thirteen percent of treatment initiators achieved biochemically confirmed 7-day point-prevalence abstinence at I year, with no significant treatment, effects. Minority patients showed greater initial interest but less utilization than did White patients. Conclusions. Free, readily accessible smoking cessation treatment offered in primary care settings was accepted and used by the majority of unselected smokers of diverse racial/ethnic origins. Psychosocial treatment components did not significantly increase abstinence rates. Barriers, rather than lack of interest, may keep minority smokers from using cessation treatments.

Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care.

Ford JD; Trestman RL; Steinberg K; Tennen H; Allen S. Social Science & Medicine 58(11): 2145-2148, 2004. (17 refs.)
The empirical evidence concerning the relationship of psychiatric disorders to health care utilization and costs is mixed and primarily retrospective. Therefore, a case-control study was conducted to prospectively examine the association of psychiatric disorders with health care utilization in an adult primary care internal medicine patient population, controlling for the effects of medical morbidity, adverse events, age, race, gender, employment status, and health insurance coverage. Samples of primary care high utilizer (HU; 125 men, 125 women with primary care visits in 1998 above the 95th percentile) vs. mid-range utilizer (MU; 125 men, 125 women; two primary care visits in 1998) patients were compared using archival automated medical record data from the index year (1998), and from the following year (1999) for prospective analyses. HU (compared to MU) participants were younger, had higher medical and psychiatric morbidity, and had higher levels of outpatient specialty medical care utilization. In multivariate analyses, (a) anxiety disorder diagnoses uniquely contributed to identifying HU patients, and (b) after controlling for initial primary care utilization status, anxiety, depressive and addictive disorders were prospectively associated with medical illness complexity and primary, specialty, and emergency medical care utilization. Although behavioral health disorders (including addictive as well as depressive and anxiety diagnoses) and high utilization of primary health care services are related, these prospective findings suggest that behavioral health disorders make an independent contribution to non-psychiatric health care utilization.

Buprenorphine for office-based practice: Consensus conference overview.

Kosten TR; Fiellin DA. American Journal on Addictions 13(Supplement 1): S1-S7, 2004. (3 refs.)
This overview of the March 2003 conference on the U.S. national buprenorphine implementation program is developed to inform the practitioner about the positive experience that has been accumulated worldwide on the use of buprenorphine for office-based practice. The first paper delineates the challenges for American psychiatry in moving buprenorphine forward into general practice. Most psychiatrists are unprepared to work with opiate-dependent patients or to use buprenorphine. The international successes with office-based buprenorphine from France and Australia are presented in the next papers, followed by presentations on several U.S. studies using buprenorphine in the community for detoxification and office-based maintenance. These experiences have thus far confirmed buprenorphine's utility and promise for opiate addiction two national monitoring programs have treatment in the U.S. Finally, two national monitoring programs have been implemented to assess the public health impact of this new treatment opportunity. This opportunity has a three-year window, however, and a critical need will be to attract a sufficient number of physicians into prescribing buprenorphine/naloxone in order to allow our patients increased access to this treatment.

Seeking drugs or seeking help? Escalating "doctor shopping" by young heroin users before fatal overdose.

Martyres RF; Clode D; Burns JM. Medical Journal of Australia 180(5): 211-214, 2004. (23 refs.)
Objective: To identify prescription drug-seeking behaviour patterns among young people who subsequently died of heroin-related overdose. Design: Linkage of Medicare and Pharmaceutical Benefits Scheme and Coroner's Court records from Victoria. Subjects: Two hundred and two 15-24-year-olds who died of heroin-related overdose between 6 January 1994 and 6 October 1999.Main outcome measures: Patterns of use of medical services and prescription drugs listed on the Pharmaceutical Benefits Scheme in the years before death, and use of all drugs just before death. Results: Polydrug use was reported in 90% of toxicology reports, and prescription drugs were present in 80% of subjects. Subjects accessed medical services six times more frequently than the general population aged 14-24 years, and more than half of all prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics. A pattern of increasing drug-seeking behaviour in the years before death was identified, with doctor-visitation rates, number of different doctors seen and rates of prescriptions peaking in the year before death. Conclusions: An apparent increase in "doctor shopping" in the years before heroin-related death may reflect the increasing misuse of prescription drugs, but also an increasing need for help. Identification of a pattern of escalating doctor shopping could be an opportunity for intervention, and potentially, reduction in mortality.

Encouraging GP alcohol intervention: Pilot study of change-orientated reflective listening (CORL).

McCambridge J; Platts S; Whooley D; Strang J. Alcohol and Alcoholism 39(2): 146-149, 2004. (18 refs.)
Aims: To test the feasibility of delivery and potential value of a brief motivational enhancement intervention targeting GPs in relation to alcohol as a public health issue, and to compare data obtained with similar attempts to influence GP intervention with drug users. Method: 21 GPs who were not involved in the treatment of drug dependence received a telephone-administered 'change-orientated reflective listening' (CORL) intervention, based on Motivational Interviewing, with an informational adjunct. Assessments were made at baseline and at 2-3 months of activity and willingness to deliver specified alcohol-related interventions, plus overall therapeutic commitment and motivation. Qualitative data was obtained. Results: There was no change over time in the sample as a whole, with very modest evidence of benefit among individual practitioners. Comparisons with cannabis and drug misuse intervention targets suggest that it may be more difficult to alter views on intervening with drinkers. Conclusions: Further attempts are needed to influence practitioner motivation, based on improved understanding of GP views on the delivery of alcohol interventions.

The right of minors to confidentiality and informed consent.

Weisleder P. Journal of Child Neurology 19(2): 145-148, 2004. (23 refs.)
Doctor-patient confidentiality is a precept of adolescent medicine. In general, physicians honor the privacy of adolescents unless there is evidence that the youngster is engaging in dangerous activities. An otherwise healthy 16 year old was referred for headache evaluation. During the portion of the interview conducted outside the presence of his mother, the patient revealed using marijuana and cocaine regularly and LSD (lysergic acid diethylamide), hallucinogenic mushrooms, and "Ecstasy" (3,4-methylenedioxymethaniphetamine) occasionally. Given this information, and as allowed by North Carolina's General Statutes, the patient was offered confidential treatment for illegal substance abuse; he declined the offer. He also turned down the request to forgo his right to privacy so that his parents could be made aware of his addiction. As a result of the patient's drug use and disregard of its consequences, it was determined that notification of a parent was essential to his life or health; thus, confidentiality was breached. Although substance abuse is a behavior that threatens the abuser's health and life, state and federal laws vary regarding the rights of minors to confidential evaluation and treatment. For this article, laws that govern minors' rights to consent to confidential treatment for illegal substance abuse were reviewed. The aforementioned case is used as a catalyst for discussion.

The psychiatric sequelae of human rights violations: A challenge for primary health care.

Zungu-Dirwayi N; Kaminer D; Mbanga I; Stein DJ. Journal of Nervous and Mental Disease 192(4): 255-259, 2004. (23 refs.)
High rates of psychiatric morbidity have been documented in survivors of gross human rights abuses. Nevertheless, there has been relatively little focus on such patients in the context of primary care medicine. A sample of 134 survivors of gross human rights violations was assessed using a structured interview to determine exposure to violations and psychiatric status. In addition, psychiatric treatment history was probed with an open-ended interview. The study found that of the 95 of 134 (72%) participants who were assessed and found to have a current psychiatric diagnosis, only three were receiving treatment for such a disorder. Many subjects had presented to primary care clinics with somatic symptoms and had been prescribed benzodiazepines. Reasons for not reporting trauma or not seeking treatment included issues revolving around fear and mistrust, privacy and confidentiality, re-experiencing the trauma, and lack of awareness. Misdiagnosis and ineffective treatment of survivors of human rights abuses are likely to pose a significant drain on primary care resources. Accurate diagnosis and appropriate treatment are important challenges in primary care settings.

Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?

Lock CA; Kaner EFS. Family Practice 21(3): 270-275, 2004. (50 refs.)
Background. In the UK, GPs and practice nurses selectively provide brief alcohol interventions to risk drinkers. GPs' provision of a brief alcohol intervention can be predicted by patient characteristics, practitioner characteristics and structural factors such as the features of the practice and how it is organized. However, much less is known about possible modifiers of nurse practice. Objective. Our aim was to investigate if patient characteristics, nurse characteristics and practice factors influence provision of a brief alcohol intervention by practice nurses in primary health care. Methods. One hundred and twenty-eight practice nurses who had implemented a brief alcohol intervention programme in a previous trial based in the North of England were requested to screen adults presenting to their surgery and follow a structured protocol to give a brief intervention (5 min of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of 5541 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires were collected after a 3-month implementation period and analysed by logistic regression analysis. Results. Although AUDIT identified 1500 'risk' drinkers, only 926 (62%) received a brief intervention. Logistic regression modelling showed that patients' risk status as measured by AUDIT score was the most influential predictor of a brief intervention by practice nurses. However, risk drinkers who were most likely to receive a brief intervention were male. Patients' age or social class did not independently predict a brief intervention. The multilevel model was unable to identify any independent nurse characteristics that could predict a brief intervention, but indicated significant variation between nurses in their tendency to offer the intervention to patients. No structural factors were found to be positively associated with selective provision. Conclusions. Patient and nurse factors contributed to the selective provision of a brief intervention in primary care. If patients are to experience the beneficial effects of a brief alcohol intervention, then there is a need to improve the accuracy of delivery.

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