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...on Primary Care
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www.ProjectCork.org
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Winter 2004
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The role of general practitioners' working style
and brief alcohol intervention activity.
Aalto M; Varre T; Pekuri P; Seppa K. Addiction 98(10):
1447-1451, 2003. (19 refs.)
Aims: To examine correlates of general practitioners' (GP) activity delivery
of brief alcohol interventions to patients with particular reference to
their 'working style'. Design: A postal questionnaire survey. Setting and
participants All 75 GPs in the Community Primary Health Care Centre of
the City of Tampere, Finland. Measurements Measures of working style classifying
GPs into 'problem solving' versus 'technological', self-reported brief
advice activity and other demographic details. Findings and conclusions
Of the respondents (response rate 85%) 45%, (29/64) reported carrying out
brief alcohol interventions. Male GPs provided brief interventions more
often than female GPs (71% versus 36%, P = 0.017). The respondents had
mainly positive attitudes to brief interventions for excessive drinkers.
The working style typology did not show any relationship with brief intervention
activity.
Copyright 2003, Society for the Study of Addiction to
Alcohol and Other Drugs.
Pediatric smoking prevention interventions delivered by care providers:
A systematic review. (review).
Christakis DA; Garrison MM; Ebel BE; Wiehe SE; Rivara FP. American Journal
of Preventive Medicine 25(4): 358-362, 2003. (28 refs.)
Objective: To conduct a systematic review of randomized controlled trials
of smoking prevention interventions for youth delivered via medical or
dental providers' offices. Methods: Online bibliographic databases were
searched as of July 2002, and reference lists from review articles and
the selected articles were also reviewed for potential studies. The methodology
and findings of all retrieved articles were critically evaluated. Data
were extracted from each article regarding study methods, intervention
studied, outcomes measured, and results. Results: The literature search
returned 81 abstracts from MEDLINE and 49 from Cochrane Clinical Trials
Registry (CCTR); of these, four articles met the inclusion criteria. Included
were two studies conducted in primary care, and one each in dental and
orthodontic offices. Only one study demonstrated a significant effect on
smoking initiation; in that study, 5.1% of the intervention group and 7.8%
of the control group reported smoking at 12-month follow-up (odds ratio
= 0.63; 95% confidence interval, 0.44-0.91). None of the studies had follow-up
times greater than 3 years. Conclusions: There is very limited available
evidence demonstrating efficacy of smoking prevention interventions in
adolescents conducted in providers' offices and no evidence for long-term
effectiveness of such interventions.
Copyright 2003, American College of Preventive Medicine.
Health care practitioners' motivation for tobacco-dependence counseling.
Williams GC; Levesque C; Zeldman A; Wright S; Deci EL. Health Education
Research 18(5): 538-553, 2003. (24 refs.)
Smoking cessation counseling by practitioners occurs at low rates in spite
of strong evidence that counseling increases quit rates and reduces patient
mortality. In a preliminary study, 1060 New York State physicians completed
a survey concerning use of the Agency for Health Care Policy and Research
(AHCPR) Guidelines, perceived autonomy and perceived competence for counseling,
perceived autonomy support from insurers, and barriers to counseling. Considered
together, perceived autonomy, perceived competence and perceived autonomy
support predicted time devoted to counseling and use of the AHCPR guidelines.
The primary, longitudinal study of 220 health care practitioners who attended
a smoking cessation workshop predicted change in the practitioners' perceived
autonomy and perceived competence for counseling as a function of the degree
to which they experienced the workshop instructor as autonomy-supportive.
In turn, change in perceived autonomy predicted change in time spent counseling
and change in use of the AHCPR guidelines.
Copyright 2003, Oxford University Press.
Recognition and prevention of inhalant abuse.
Anderson CE; Loomis GA. American Family Physician 68(5): 869-874,
2003. (22 refs.)
Inhalant abuse is a prevalent and often overlooked form of substance abuse
in adolescents. Survey results consistently show that nearly 20 percent
of children in middle school and high school have experimented with inhaled
substances. The method of delivery is inhalation of a solvent from its
container, a soaked rag, or a bag. Solvents include almost any household
cleaning agent or propellant, paint thinner, glue, and lighter fluid. Inhalant
abuse typically can cause a euphoric feeling and can become addictive.
Acute effects include sudden sniffing death syndrome, asphyxia, and serious
injuries (e.g., falls, burns, frostbite). Chronic inhalant abuse can damage
cardiac, renal, hepatic, and neurologic systems. Inhalant abuse during
pregnancy can cause fetal abnormalities. Diagnosis of inhalant abuse is
difficult and relies almost entirely on a thorough history and a high index
of suspicion. No specific laboratory tests confirm solvent inhalation.
Treatment is generally supportive, because there are no reversal agents
for inhalant intoxication. Education of young persons and their parents
is essential to decrease experimentation with inhalants.
Copyright 2003, American Academy of Family Physicians.
Used with permission.
Barriers to identification and treatment of hazardous drinkers as assessed
by urban/rural primary care doctors.
Ferguson L; Ries R; Russo J. Journal of Addictive Diseases 22(2):
79-90, 2003. (35 refs.)
This pilot study analyzed three types of barriers encountered by forty
family physicians when identifying and treating patients with hazardous
drinking and alcohol dependence. The Patient Centered category included
patient denial and lack of motivation to change. The Physician Centered
category included lack of physician time and lack of addiction medicine
training. The System Centered category included lack of community resources
and distance to treatment programs. The Patient Centered barriers were
rated significantly greater (p <.001) than the Physician Centered or the
System Centered barriers. There was also a significant negative correlation
(r = -0.49, p <.001) between the Physician Centered and the Patient Centered
categories, meaning that the more problematic the patients were rated,
the less problematic the physicians rated their time or training. The types
of barriers that were rated as most problematic varied depending on rural/urban
practice location and how current the physician's training was.
Copyright 2003, The Haworth Press, Inc.
Office-based treatment of opiate addiction with a sublingual-tablet
formulation of buprenorphine and naloxone.
Fudala PJ; Bridge TP; Herbert S; Williford WO; Chiang CN; Jones K; D. New
England Journal of Medicine 349(10): 949-958, 2003. (32 refs.)
Background: Office-based treatment of opiate addiction with a sublingual-tablet
formulation of buprenorphine and naloxone has been proposed, but its efficacy
and safety have not been well studied. Methods: We conducted a multicenter,
randomized, placebo-controlled trial involving 326 opiate-addicted persons
who were assigned to office-based treatment with sublingual tablets consisting
of buprenorphine (16 mg) in combination with naloxone (4 mg), buprenorphine
alone (16 mg), or placebo given daily for four weeks. The primary outcome
measures were the percentage of urine samples negative for opiates and
the subjects' self-reported craving for opiates. Safety data were obtained
on 461 opiate-addicted persons who participated in an open-label study
of buprenorphine and naloxone (at daily doses of up to 24 mg and 6 mg,
respectively) and another 11 persons who received this combination only
during the trial. Results: The double-blind trial was terminated early
because buprenorphine and naloxone in combination and buprenorphine alone
were found to have greater efficacy than placebo. The proportion of urine
samples that were negative for opiates was greater in the combined-treatment
and buprenorphine groups (17.8 percent and 20.7 percent, respectively)
than in the placebo group (5.8 percent, P<0.001 for both comparisons);
the active-treatment groups also reported less opiate craving (P<0.001
for both comparisons with placebo). Rates of adverse events were similar
in the active-treatment and placebo groups. During the open-label phase,
the percentage of urine samples negative for opiates ranged from 35.2 percent
to 67.4 percent. Results from the open-label follow-up study indicated
that the combined treatment was safe and well tolerated. Conclusions: Buprenorphine
and naloxone in combination and buprenorphine alone are safe and reduce
the use of opiates and the craving for opiates among opiate-addicted persons
who receive these medications in an office-based setting.
Copyright 2003, Massachusetts Medical Society.
Physicians' missed opportunities to address tobacco use during prenatal
care.
Moran S; Thorndike AN; Armstrong K; Rigotti NA. Nicotine & Tobacco Research 5(3):
363-368, 2003. (22 refs.)
Smoking cessation during pregnancy reduces the risk of adverse perinatal
outcomes and leads to long-term cessation for at least some women smokers.
Prenatal care offers repeated opportunities for smoking status identification
and smoking cessation counseling. Using cross-sectional data from the 1991-1996
National Ambulatory Medical Care Survey, we assessed how frequently physicians
caring for pregnant women identified pregnant women's smoking status and
provided counseling to pregnant smokers. Data were available from 793 physicians
reporting on 5,622 office visits by pregnant patients from 1991 through
1996. Physicians identified pregnant women's smoking status at 81% of visits
but provided smoking counseling at only 23% of visits by pregnant smokers.
Physicians were less likely to identify smoking status of non-White pregnant
women but no less likely to counsel non-White smokers. These results indicate
a clear need to improve quality of care provided to pregnant women who
use tobacco.
Copyright 2003, Carfax Publishing.
Comparison of nicotine patch alone versus nicotine nasal spray alone
versus a combination for treating smokers: A minimal intervention, randomized
multicenter trial in a nonspecialized setting.
Johnson PA; Tschetter LK; Loprinzi C. Nicotine & Tobacco Research 5(2):
181-187, 2003. (28 refs.)
This multicenter, randomized, open-label clinical trial was conducted to
determine whether the combined use of nicotine patch therapy and a nicotine
nasal spray would improve smoking abstinence rates compared to either treatment
alone, without behavioral counseling. Data were collected at 15 regional
cancer control oncology centers within the North Central Cancer Treatment
Group. Of the 1384 smokers randomized to the study, 20% were abstinent
from smoking at 6 weeks and 8% were abstinent at 6 months. At 6 weeks,
the 7-day point prevalence smoking abstinence rate for the patch alone
(21.1%) was superior to the spray (13.6%) but was significantly lower than
the rate for combination therapy (27.1%). At 6 months, the 7-day point
prevalence abstinence rates were not significantly different among the
three groups. Combination nicotine nasal spray and nicotine patches were
delivered safely in a nonspecialized outpatient clinical setting and enhanced
short-term smoking abstinence rates, but these rates were not sustained
at 6 months.
Copyright 2003, Carfax Publishing.
The primary prevention of heart disease in women through health behavior
change promotion in primary care.
Whitlock EP; Williams SB. Women's Health Issues13(4): 122-141, 2003.
(62 refs.)
Purpose. To summarize recent evidence-based recommendations for physical
activity promotion, dietary improvement, and tobacco cessation from the
U.S. Preventive Services Task Force (USPSTF) and the Task Force on Community
Preventive Services (CTF), and examine their applicability to the primary
prevention of cardiovascular disease (CVD) in women through primary care
interventions. Methods. For the behaviors cited, USPSTF and CTF recommendations
and their associated systematic evidence reviews (SERs) were retrieved.
Individual articles from the USPSTF healthy diet and physical activity
SERs that met our inclusion criteria were systematically examined to determine
the applicability of this research to women. We supplemented findings from
these sources with comprehensive federal research summaries and SERs from
focused searches of systematic review databases relevant to primary CVD
prevention in women through healthy behavior change. Main Findings. The
USPSTF strongly recommends primary care interventions for tobacco cessation.
Strong CTF recommendations for multicomponent systems supports for clinicians,
telephone support for quitters, and reduced patient costs for effective
cessation therapies guide complementary approaches to assist clinicians.
The USPSTF recommends intensive behavioral dietary counseling by specialists
for high-risk CVD patients, but found insufficient evidence to recommend
for routine healthy diet or physical activity promotion in primary care.
The evidence base for these recommendations generally applies to women.
Better reporting of gender and minority subgroup outcomes will assist more
in-depth understanding of potential differences in either the processes
or outcomes of behavior change interventions. Conclusions. Primary care
clinicians, including obstetrician-gynecologists, can contribute to preventing
CVD in women through implementing credible evidence-based recommendations
for clinical interventions in tobacco and healthy diet. Researchers can
further our understanding of gender-specific issues in healthy behavior
interventions by reporting process and outcome data for gender and minority
subgroups.
Copyright 2003, Elsevier Science Ltd.
Smoking status identification: Two managed care organizations' experiences
with a pilot project to implement identification systems in independent
practice associations.
Marcy TW; Thabault P; Olson J; Tooze JA; Liberty B; Nolan S. American
Journal of Managed Care 9(10): 672-676, 2003. (14 refs.)
Objective: To determine whether managed care organizations (MCOs) can effectively
promote the sustained use of smoking status identification systems among
independent practice associations. Study Design: Quasi-experimental design
measuring smoking status documentation before and after an intervention.
Methods: A chart review of the MCOs' patients at 4 participating primary
care clinics determined the baseline for smoking status documentation before
intervention. Baseline data were unavailable from a fifth participating
clinic. Two quality improvement personnel were sent by the MCOs to help
the clinics chose and implement a system for identifying smoking status.
All of the clinics chose a sticker system. The change in smoking status
documentation was assessed by chart reviews of patients enrolled in the
MCOs who were seen during the period between 3 and 16 months after implementation
of the system. Results: Following the intervention, a significant increase
in smoking status documentation was noted among participating clinics.
The proportion of patients whose smoking status was identified and documented
by any method increased from 50% to 87% (P < .01) at the 4 clinics with
baseline data. By clinic, the increase varied from 6% to 60%. The sticker
system was the method by which most patients' smoking status was documented
(77%). There were no controls, so the influence of outside factors, including
a regional smoking cessation campaign that coincided with this study, cannot
be quantified. Conclusions: Managed care organizations may be an effective
change agent for implementing the guidelines for tobacco use and dependence
treatment.
Copyright 2003, American Medical Publishing.
Evaluation of buprenorphine maintenance treatment in a French cohort
of HIV-infected injecting drug users.
Carrieri MP; Rey D; Loundou A; Lepeu G; Sobel A; Obadia Y; The MANIF-2000
Study Group. Drug and Alcohol Dependence 72(1): 13-21, 2003. (57
refs.)
Background: Buprenorphine was approved in France for treating opiate dependence
in July 1995 and can be prescribed by general practitioners (GPs). Most
studies assessing buprenorphine maintenance treatment (BMT) outcomes have
taken place in GP settings. An evaluation of BMT outcomes in patients already
followed for their HIV-infection could supply additional information about
the changes in addictive practices in a non-GP setting. Methods: We assessed
BMT discontinuations and the course of self-reported addictive behaviours
and characteristics associated with buprenorphine-injection misuse in 114
HIV-infected patients on BMT who were followed in a hospital-based outpatient
department. Results: The continuous series of follow-up visits at which
these 114 patients reported regular buprenorphine prescriptions accounted
for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the
114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped
it, and results for 17% were not available either because they did not
answer the self-administered questionnaire (5%) or because they were lost
to follow-up (12%). Addictive behaviours declined but buprenorphine injection
misuse remained stable. Depression measured by the CESD score (RR=1.04
95%CI, cocaine use (RR=2.48 95%CI and alcohol consumption exceeding 4 alcohol
units (AU) per day (RR=2.29, 95%CI were independently associated with buprenorphine
injection misuse among stabilised BMT patients. Conclusions: Despite the
reduction in drug injection after starting BMT, buprenorphine injection
misuse mainly involves patients with characteristics of severe addiction.
Better monitoring of the illicit drug use patterns of patients on BMT may
suggest new medical strategies for GPs to improve BMT outcomes.
Copyright 2003, Elsevier Science.
Substance abuse during pregnancy: Clinical and public health approaches.
Jos PH; Perlmutter M; Marshall MF. Journal of Law, Medicine & Ethics 31(3):
340-350, 2003. (74 refs.)
The authors explore the issues related to interventions involving drug-using
women during pregnancy. Currently there are thirty-five states that have
criminally proscuted women for substance abuse or alcohol use during pregnancy.
In addition involuntary commitment has been used to protect fetus. There
have also been mandatory reporting mechanisms for health care professionals
that has generated concerns. This essay acknowledges the concerns about
need to protect the clinical encounter from intrusion by government, HMOs,
or insurers. This essay approaches the issues of maternal addiction through
a public health model. It presents what the authors view as inherent limits
is the clinical encounter, and the problems which arise from the intrusion
in the clinical encounter. The key elements of a public health approach
is described which includes attention to macro-level policy and programs
rooted in the community.
Copyright 2003, American Society of Law, Medicine and
Ethics.
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