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...on Substance Abuse and Primary Care
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www.ProjectCork.org
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Spring 2005
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Alcohol and public health. (review).
Room R; Babor T; Rehm J. Lancet 365(9458): 519-530, 2005. (145 refs.)
Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of alcohol's role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy research and options. Research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective, and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative. Copyright 2005, Lancet Ltd.
Alcohol-related advice for Veterans Affairs primary care patients: Who gets it? Who gives it?
Burman ML; Kivlahan D; Buchbinder M; Broglio K; Zhou XH; Merrill JO. Journal of Studies on Alcohol 65(5): 621-630, 2004. (38 refs.)
Objective: Most patients who misuse alcohol do not receive alcohol counseling from their providers. This study evaluated primary care patient and provider characteristics associated with receipt of alcohol-related advice and whether patients were advised to drink less or to abstain. Method: Outpatients from seven Veterans Affairs (VA) general medicine clinics were eligible if they screened positive for alcohol misuse, completed the Alcohol Use Disorders Identification Test (AUDIT) and answered questions about alcohol-related treatment and advice. Hierarchical logistic regression wag used to evaluate patient and provider characteristics associated with patient reports of alcohol-related advice from a primary care provider in the past year. Results: Among 5,191 patients with alcohol misuse in the past year, 1,554 (30%) reported receiving alcohol-related advice from their primary care provider during that time. Of patients advised, 73% reported advice to abstain. The likelihood of reporting advice increased as AUDIT scores increased: from 13% of patients with AUDIT scores <8 to 71% of those with scores greater than or equal to20. After adjustment for important confounders, measures reflecting the severity of alcohol misuse were most strongly associated with receipt of alcohol-related advice. Adjusted analyses also revealed increased odds of receiving advice among patients who reported liver disease, hypertension, current smoking or continuity of care. No measured provider characteristic was associated with giving advice in the fully adjusted model. Conclusions: This multisite VA study found that most patients with alcohol misuse did not receive alcohol counseling from a primary care provider. Moreover, providers predominantly offered advice to abstain, and they appeared to focus on patients with the most severe problems due to drinking or medical contraindications to drinking. Copyright 2004, Alcohol Research Documentation Inc.
Are clinical impressions of adolescent substance use accurate?
Wilson CR; Sherritt L; Gates E; Knight JR. Pediatrics 114(5): E536-E540, 2004. (22 refs.)
Objective. To compare providers' impressions of adolescents' level of substance use with diagnostic classifications from a structured diagnostic interview. Methods. Secondary analysis of data was conducted from a validation study of the CRAFFT substance abuse screening test of 14- to 18-year-old medical clinic patients (n = 533) and their corresponding medical care providers (n = 109) at an adolescent clinic affiliated with a large tertiary care pediatric hospital. Medical care providers completed a form that recorded their clinical impressions of patients' level of alcohol and drug involvement (none, minimal, problem, abuse, dependence) and demographic characteristics. The form included brief diagnostic descriptions for each level of use. After the medical visit, patients completed the Adolescent Diagnostic Interview (ADI), a structured diagnostic interview that yields diagnoses of abuse and dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). On the basis of their past 12 months of alcohol and drug use on the ADI interview, adolescents were classified into 5 mutually exclusive diagnostic groups. "None" was defined by no reported use of alcohol or drugs during the past year. "Minimal use" was defined as use of alcohol or drugs but no report of any substance-related problems. "Problem use" was defined as reporting 1 or more substance-related problems but no diagnosis of abuse or dependence. "Abuse" was defined by meeting any 1 of 4 DSM-IV diagnostic criteria for either alcohol or drug abuse but no diagnosis of dependence. "Dependence" was defined by meeting any 3 of 7 diagnostic criteria for either alcohol or drug dependence, with or without a diagnosis of abuse. Proportions were compared using Fisher exact test. Agreement was assessed with the weighted kappa, and these analyses were stratified by substance used (ie, alcohol vs drug) and demographic characteristics. Sensitivity, specificity, and positive and negative predictive values were calculated from 2 x 2 tables. Results. Compared with the criterion standard interview, providers identified significantly fewer patients with problem use and abuse and no patients with dependence. Of >100 patients whom the ADI classified with substance problem use, providers correctly identified 18. Of 50 patients who were classified with a diagnosis of alcohol or drug abuse, providers correctly identified 10. Of 36 patients who were classified with a diagnosis of alcohol or drug dependence, providers correctly identified none. For the 86 adolescents who were classified with a substance-related disorder (ie, abuse or dependence), providers' impressions were "none" (24.4%), "minimal use" (50%), "problem use" (15.1%), "abuse" (10.5%), and "dependence" (0%). There was only marginal agreement between providers' impressions and diagnoses related to alcohol use. Of the 86 adolescents with a diagnosis of abuse or dependence, 75.6% were correctly identified by providers as using substances; however, the level of use in 50% of these adolescents was reported by providers as minimal. Conclusions. In this study, clinical impressions of adolescents' alcohol/drug involvement underestimated substance-related pathology. When providers thought that use was present, there was a very high likelihood that a problem or disorder existed. The use of structured screening devices would likely improve identification of adolescents with substance-related pathology in primary care settings and should be considered for use with all adolescent patients, rather than only those who are perceived to be at higher risk. Copyright 2004, American Academy of Pediatrics.
Computerized screening of substance abuse problems in a primary care setting: Older vs. younger adults.
Nemes S; Rao PA; Zeiler C; Munly K; Holtz KD; Hoffman J. American Journal of Drug and Alcohol Abuse 30(3): 627-642, 2004. (22 refs.)
The purpose of the current study was to examine differences in responses of older adults (age 55 and above) and younger, adults (ages 18 to 54) to the Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings. Data were collected from a diverse population of 327 adults presenting for care at The George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Results indicated that rates of drug and alcohol abuse were similar in both groups. However, older adults were less likely than younger adults to perceive their drug use as problematic. This finding has serious implications for older adults, who tend to be underrepresented in treatment programs. There is a need for screening seniors and identifying those who may be at risk for substance abuse problems. Differences in responses to alcohol and drug assessments by age should be taken into consideration when designing screening instruments. The results of this study suggest that the DAPA-PC would provide a useful instrument for screening older adults in a primary care setting. Copyright 2004, Marcel Dekker.
Hepatitis C among drug users: Consensus guidelines on management in general practice.
Cullen W; CA; Dublin; Area; Hepatitis; C; Initative. Irish Journal of Medical Science 173(3): 145-150, 2004. (46 refs.)
Background: Hepatitis C (HCV) is a common cause of morbidity among patients who attend general practitioners (GPs) in Ireland for methadone maintenance treatment. Aims To describe the development and content of guidelines for the management of HCV among current or former opiate users in the Eastern Regional Health Authority area attending GPs for methadone treatment. Methods: The guidelines were produced in five stages: identification of key stakeholders; development of evidence-based draft guidelines; discussion of content; determination of 'Delphi'-facilitated consensus and review by a sample of GPs for whom the guidelines would be intended. Results: The guidelines contain advice for GPs on all aspects of care of patients at risk of HCV, including general and preventative care, care of other bloodborne and hepatotoxic viruses, and the factors to be considered and appropriate evaluation prior to referring a patient for assessment at a hepatology unit. Conclusions: GPs have an important role to play in the care of patients at risk of, or infected with, HCV. Copyright 2004, Royal Academy of Medicine.
Smoking in adolescence: What a clinician can do to help.
Sunday SR; Folan P. Medical Clinics of North America 88(6): 1495+, 2004. (93 refs.)
Approximately 4400 adolescents try their first cigarette every day in the United States. Trying a few cigarettes or using tobacco more regularly as an adolescent significantly increases the risk of smoking in adulthood. Adolescents can develop nicotine dependency after smoking relatively few cigarettes. This article points out the prevalence and unique aspects of teenage tobacco use. In addition, current recommendations for treating nicotine dependence in adolescents are reviewed. Copyright 2004, WB Saunders Co.
Usefulness, length and content of alcohol-related discussions in primary health care: The exit poll survey.
AAlto M; Seppa K. Alcohol and Alcoholism 39(6): 532-535, 2004. (22 refs.)
Aims: To evaluate patients' opinions of the usefulness of alcohol-related discussions with general practitioners (GPs), the time used for the discussion and its main content. Methods: Exit poll survey to 2000 consecutive patients right after GP consultations. Results: The response rate was 60.2% (1203/2000). Of the patients 11.6% (139/1203) reported that they were asked and/or advised about alcohol during the consultation. The time used for discussion about alcohol was mostly <4 min; longer for heavy than for non-heavy drinkers. Main topics of the discussion dealt with quantities consumed and harm caused by alcohol. The majority of the patients (81%) reported that discussions concerning alcohol were useful. In that respect heavy drinkers did not differ from non-heavy drinkers. Conclusions: Discussions about alcohol in primary health care were rare and short, but patients' opinions about their usefulness were mainly positive. Copyright 2004, Oxford University Press
Use of alcohol screening and brief interventions in primary care settings: Implementation and barriers.
Barry KL; Blow FC; Willenbring M; McCormick R; Brockmann LM; Visnic S. Substance Abuse 25(1): 27-36, 2004. (42 refs.)
Although evidence indicates that brief alcohol screening and interventions are effective across primary care settings, implementation of these techniques has been problematic. The primary objective of this study was to determine current practices and barriers for screening and interventions with primary care patients across randomly selected clinics in a large health care system, the Veterans Health Administration. Focus groups and mailed structured surveys were used. Results from providers indicated that 85% of patients treated in primary care received some screening for alcohol use disorders. The CAGE was the predominant screening tool. The primary clinical focus was on treatment referrals for patients who met abuse/dependence criteria. Lack of time was the most important perceived barrier to implementing screening and brief alcohol interventions for at-risk and problem drinkers. Implications for implementation of screening and intervention programs for a range of drinkers (at-risk use, problem use, abuse, dependence) are discussed. Copyright 2004, Haworth Press.
Brief motivational intervention at a clinic visit reduces cocaine and heroin use.
Bernstein J; Bernstein E; Tassiopoulos K; Heeren T; Levenson S; Hingson R. Drug and Alcohol Dependence 77(1): 49-59, 2005. (28 refs.)
Background: Brief intervention is effective for alcohol misuse, but not adequately tested in the clinical setting with drug using patients. This study tested the impact of a single, structured encounter targeting cessation of drug use. conducted between peer educators and ow-of-treatment cocaine and heroin users screened in the context of a routine medical visit. Methods: A randomized, controlled trial was conducted in inner-city teaching hospital outpatient clinics with 3 and 6 months follow-up by blinded observers. Drug abstinence was documented by RIA hair testing. Analysis was limited to enrollees with drug-positive hair at baseline. Results: Among 23,669 patients screened 5/98-11/00, 1232 (5%) were eligible. and 1175 enrolled. Enrollees (mean age 38 years) were 29% female, 62% non-hispanic black, 23% hispanic, 46% homeless. Among those with positive hair at entry, the follow-up rate was 82%.The intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% versus 16.9%). heroin alone (40.2% versus 30.6%), and both drugs (17.4% versus 12.8%), vith adjusted OR of 1.51-1.57. Cocaine levels in hair were reduced by 29%, for the intervention group and only 4% for the control group. Reductions in opiate levels were similar (29% versus 25%). Conclusions: Brief motivational intervention may help patients achieve abstinence from heroin and cocaine. Copyright 2005, Elsevier Science Ireland, Ltd.
Counseling requirements for buprenorphine maintenance in primary care: Lessons learned from a preliminary study in a methadone maintenance program.
Pantalon MV; Fiellin DA; O'Connor PG; Chawarski MC; Pakes JR; Schottenfeld RS. Addictive Disorders and Their Treatment 3(2): 71-76, 2004. (13 refs.)
Objective: This preliminary study was conducted to establish the minimal counseling requirements for buprenorphine maintenance in primary care settings. A brief, nurse-administered, medically focused counseling approach for buprenorphine-maintained patients, Medical Management (MM), was designed by the authors. To evaluate preliminary feasibility and efficacy of MM prior to using it in a primary care setting, we evaluated it in a methadone maintenance program. Method: Fourteen opioid dependent patients were treated for 12 weeks with thrice-weekly buprenorphine plus either MM provided thrice weekly (5-10 minutes) by an RN, or MM plus individual Drug Counseling (MM+DC). DC was provided weekly (45 minutes) by a Ph.D.-level psychologist or a Certified Alcohol and Drug Counselor. Results: Seven of the 7 MM and 6 of the 7 MM+DC patients completed all 12 weeks of the study. Rates of opioid-positive urine toxicology tests averaged 72% for MM and 54% for MM+DC. Two of the 7 MM and 4 of the 7 MM+DC patients achieved >=3 consecutive weeks of opioid-negative urine toxicology tests. None of these differences reached statistical significance. Conclusions: These preliminary findings demonstrate the feasibility and efficacy of MM and suggest, as with methadone, that DC may be a necessary component of buprenorphine treatment of opioid dependence. Therefore, providers of office- or primary care-based buprenorphine maintenance may need to incorporate aspects of drug counseling. Copyright 2004, Lippincott, Williams & Wilkins.
Office-based intervention for tobacco dependence.
Swartz SH; Hays JT. Medical Clinics of North America 88(6): 1623+, 2004. (45 refs.)
A successful office approach for any behaviour change, including for tobacco, makes the intervention part of the everyday work of the medical practice. This article recommends how to integrate tobacco treatments efficiently into clinical practice. Specific ways to think systematically about smoking cessation and intervene with patients are discussed. Strategies to implement office-based changes to improve tobacco intervention are then presented. Copyright 2004, WB Saunders Co.
Screening and brief alcohol interventions: What, why, who, where and when? A review of the literature.
Lock CA. Journal of Substance Use 9(2): 91-101, 2004. (93 refs.)
There is a significant body of literature in the field of screening and brief alcohol intervention. This paper reviews that literature in order to provide a comprehensive overview of this important field of study. The format of the paper is not intended to be one of a systematic review with meta-analysis, but rather a gathering of data to give readers a concise summary of the vast quantity of literature relating to screening and brief alcohol intervention. The review will provide a working definition of screening and brief intervention and explain why it is considered to be an important element of preventive care. Data will also be presented relating to the effectiveness, attitudes, involvement, cost and accuracy of a variety of health professionals involved in screening and brief intervention along with the patient's perspective on these health professionals' roles. The review will also examine the settings in which screening and brief intervention can and does take place. Copyright 2004, Taylor and Francis.
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