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...on Substance Abuse and Primary Care |
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Summer 2005 |
A brief measure of high nicotine dependence for busy clinicians and large epidemiological surveys.
Diaz FJ; Jane M; Salto E; Pardell H; Salleras L; Pinet C; de Leon J. Australian and New Zealand Journal of Psychiatry 39(3): 161-168, 2005. (45 refs.)Objective: It is important to perform a routine screening of nicotine dependence in psychiatric patients. The Fagerstrom Test for Nicotine Dependence (FTND) is a widely used six-item questionnaire. The Heavy Smoking Index (HSI) is a briefer measure including only two FTND items (time to first cigarette of day and number of daily cigarettes). In a prior study comparing HSI with FTND, a high HSI (score greater than or equal to 4) was a good and briefer alternative for detecting high nicotine dependence. The goals of this study were: (i) to compare the effectiveness of the HSI with the effectiveness of Items 1 and 4 alone for the screening of high nicotine dependence; (ii) to investigate the optimality of 4 as a cut-off score for the HSI so that the HSI can be used as a binary indicator of high nicotine dependence; and (iii) to compare the sensitivity and specificity of four indexes of high nicotine dependence, namely 'High HSI', 'Very Early Smoking', 'Heavy Smoking' and 'High in Either Item'. Method: The FTND was administered to 819 current daily smokers from a general population survey. As in a prior study, an FTND score greater than or equal to 6 was considered the reference or 'gold standard' test for detecting high nicotine dependence. Receiver-operating characteristic analyses were performed. Results: This new study using more sophisticated statistical methodology verified that a cut-off of 4 for the HSI is appropriate and that the 'high' HSI has good sensitivity and specificity even across different population subclassifications. Conclusions: With four questions (smoking, daily smoking, time to first cigarette of day and number of daily cigarettes) and minimal calculations, it may be possible to screen whether a smoker has high nicotine dependence. If other studies in other populations and settings verify this finding, this brief measure might be an ideal screening instrument for busy clinicians, epidemiologists developing questionnaires for health surveys and psychiatric researchers.
Copyright 2005, Royal Australian and New Zealand College of Psychiatrists.
Preoperative smoking cessation: The role of the primary care provider. (review).
Warner DO. Mayo Clinic Proceedings 80(2): 252-258, 2005. (26 refs.)Millions of cigarette smokers require surgery each year. Those who quit smoking may reduce their risk of respiratory, cardiovascular, and wound-related complications. Scheduling of surgery may present a unique opportunity to help smokers quit permanently. Primary care providers can play an important role in helping their patients scheduled for surgery quit smoking before their operation and maintain their abstinence after surgery. To do so effectively, physicians need to understand (1) the consequences of smoking in the perioperative period and how quitting can mitigate these problems, (2) how surgery can serve as a "teachable moment" to aid in smoking cessation, and (3) specific techniques that can be used to help their patients quit smoking, including brief counseling and pharmacotherapy.
Copyright 2005, Mayo Clinic Foundation.
Provision of health counseling in office-based practices and hospital outpatient clinics.
Lin SX; Hyman D; Larson E. Preventive Medicine 40(5): 542-546, 2005. (22 refs.)Objective. To compare the rates of health counseling provided during primary care visits in two different types of ambulatory care settings. Methods. Secondary analysis of the 2000 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Results. Of the estimated 722 million adult ambulatory care visits during 2000, 90.8% were made to office-based physician practice settings and 9.2% to hospital-based outpatient departments. Consistent with previous reports, the demographic profile of patients who seek primary care in hospital outpatient departments differs from those seen in office-based practices. Provision of health counseling for exercise [OR = 1.4; 95% confidence intervals (Cl): 1-1.8], diet (OR = 1.6; 95% CI: 1.2-2.3), breast self-exam (OR = 2; 95% Cl: 1.1-3.6) and stress management (OR = 1.7; 95% CI: 1-2.7) during patient visits was more likely to be reported in the office-based practices than in hospital outpatient clinics. The visit-based rates of health counseling for HIV/STD prevention, tobacco use, mental health or injury prevention were low in both settings. Conclusions. There is opportunity to improve rates of preventive counseling in primary care settings and to reduce disparities that exist. Identifying the reasons for these disparities and effective interventions will be important steps in providing equitable care in the area of preventive health counseling.
Copyright 2005, The Institute For Cancer Prevention.
Secondhand smoke, dietary fruit intake, road traffic exposures, and the prevalence of asthma: A cross-sectional study in young children.
Lewis SA; Antoniak M; Venn AJ; Davies L; Goodwin A; Salfield N et al. American Journal of Epidemiology 161(5): 406-411, 2005. (23 refs.)The authors have investigated the independent effects of exposure to secondhand smoke, road vehicle traffic, and dietary fruit intake in a cross-sectional study of asthma in young children. They surveyed all children aged 4-6 years in 235 schools in the East Midlands and East of England regions of the United Kingdom in 2003. Data on respiratory symptoms, diagnoses and treatment, smoking in the home, and dietary fruit intake were collected by parental questionnaire. A geographic information system was used to map postcodes and determine the distance of the home from the nearest main road. Responses were obtained from 11,562 children. Wheeze in the past year and physician-diagnosed asthma were reported by 14.1% and 18.2%, respectively. Both of these outcomes were more common in children who lived with a smoker, and the prevalence of asthma increased with the number of smokers in the home. Asthma prevalence was not associated with proximity of the home to a main road or with dietary fruit intake. The authors conclude that, of the potential risk factors considered in this study, preventing secondhand smoke exposure may be the most effective way of preventing asthma.
Copyright 2005, Oxford University Press.
Teen Reach: Outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care.
Hollis JF; Polen MR; Whitlock EP; Lichtenstein E; Mullooly JP; Velicer WF. Pediatrics 115(4): 981-989, 2005. (38 refs.)Objective. To test the long-term efficacy of brief counseling plus a computer-based tobacco intervention for teens being seen for routine medical care. Methods. Both smoking and nonsmoking teens, 14 to 17 years of age, who were being seen for routine visits were eligible for this 2-arm controlled trial. Staff members approached teens in waiting rooms of 7 large pediatric and family practice departments within a group-practice health maintenance organization. Of 3747 teens invited at >= 1 visits, 2526 (67%) consented and were randomized to tobacco intervention or brief dietary advice. The tobacco intervention was individually tailored on the basis of smoking status and stage of change. It included a 30-second clinician advice message, a 10-minute interactive computer program, a 5-minute motivational interview, and up to two 10-minute telephone or in-person booster sessions. The control intervention was a 5-minute motivational intervention to promote increased consumption of fruits and vegetables. Follow-up smoking status was assessed after 1 and 2 years. Results. Abstinence rates after 2 years were significantly higher for the tobacco intervention arm, relative to the control group, in the combined sample of baseline smokers and nonsmokers (odds ratio [OR]: 1.23; 95% confidence interval [CI]: 1.03-1.47). Treatment effects were particularly strong among baseline self-described smokers (OR: 2.42; 95% CI: 1.40-4.16) but were not significant for baseline nonsmokers (OR: 1.25; 95% CI: 0.97-1.61) or for those who had "experimented" in the past month at baseline (OR: 0.95; 95% CI: 0.45-1.98). Conclusions. Brief, computer-assisted, tobacco intervention during routine medical care increased the smoking cessation rate among self-described smokers but was less effective in preventing smoking onset.
Copyright 2005, American Academy of Pediatrics.
Tobacco, alcohol, and other drugs: The role of the pediatrician in prevention, identification, and management of substance abuse.
Kulig JW; Joffe A; Behnke M; Knight JR; Kokotailo PK; Kulig JW; Committee for Substance Abuse. Pediatrics 115(3): 816-821, 2005. (34 refs.)Substance abuse remains a major public health concern, and pediatricians are uniquely positioned to assist their patients and families with its prevention, detection, and treatment. The American Academy of Pediatrics has highlighted the importance of such issues in a variety of ways, including its guidelines for preventive services. The harmful consequences of tobacco, alcohol, and other drug use are a concern of medical professionals who care for infants, children, adolescents, and young adults. Thus, pediatricians should include discussion of substance abuse as a part of routine health care, starting with the prenatal visit, and as part of ongoing anticipatory guidance. Knowledge of the nature and extent of the consequences of tobacco, alcohol, and other drug use as well as the physical, psychological, and social consequences is essential for pediatricians. Pediatricians should incorporate substance-abuse prevention into daily practice, acquire the skills necessary to identify young people at risk of substance abuse, and provide or facilitate assessment, intervention, and treatment as necessary.
Copyright 2005, American Academy of Pediatrics.
State-of-the-art interventions for office-based parental tobacco control. (review).
Winickoff JP; Berkowitz AB; Brooks K; Tanski SE; Geller A; Thomson C; American Academy of Pediatrics. Pediatrics 115(3): 750-760, 2005. (140 refs.)Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A's framework strategy ( ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.
Copyright 2005, American Academy of Pediatrics.
The World Anti-Doping Code 2003. Consequences for physicians associated with elite athletes.
Striegel H; Rossner D; Simon P; Niess AM. International Journal of Sports Medicine 26(3): 238-243, 2005. (9 refs.)The purpose of the World Anti-Doping Code 2003 and the 2004 Prohibited List is to create a universal international standard to fight doping in competitive sports. The result of this is a whole series of changes for doctors with regard to their work with competitive athletes. The revised definition of doping now includes physicians in the group of persons who can fulfill the elements of a doping offence. Moreover, the mere possession of substances appearing on the Prohibited List represents a violation of anti-doping regulations. The 2004 Prohibited List includes several changes to the Olympic Movement List from 2003. Caffeine, for example, was removed from the list. Cannabinoids, on the other hand, are now prohibited in competition for all sports. The same is true for all forms of glucocorticosteroids. Therapeutic use exemptions in an abbreviated process are possible for the administration of glucocorticosteroids by non-systemic routes, as well as inhalative therapy with the beta-2-agonists formoterol, salbutamol, salmeterol, and termbutalin. In other cases, a therapeutic use exemption is possible using a standard application process. Further changes will become effective in the 2005 Prohibited List. In 2005, it is essential that beta-2-agonists are prohibited in and out of competition. HCG and LH are prohibited for all athletes. Dermatological preparations of glucocorticosteroids are no longer prohibited, and intravenous infusions will be a prohibited method in 2005, except as a legitimate acute medical treatment. In cases of violations of anti-doping regulations where it is permissible for the affected person to furnish proof of exoneration, the burden of proof is not higher than that required to prove the violation. The sanctions provided for in the World Anti-Doping Code follow a principle of rules and exceptions which at first glance seems difficult to understand. In the case of doping violations by physicians, the anti-doping code provides - as a general rule - for exclusion from sports associations for at least four years. Since several of the changes are questionable under constitutional aspects, it remains to be seen whether the World Anti-Doping Code 2003 will allow the achievement of a universal standard to combat doping.
Copyright 2005, Georg Thieme Verlag Stuttgart.
Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: A prospective controlled intervention study.
Gorgels WJMJ; Voshaar RCO; Mol AJJ; de Lisdonk EHV; van Balkom AJLM; van den Hoogen HJM et al. Drug and Alcohol Dependence 78(1): 49-56, 2005. (28 refs.)Minimal intervention strategies to decrease long-term benzodiazepine use have not yet been evaluated in large primary care based studies with a blinded control condition and a long follow-up period. The purpose of this study was to assess the effects of a letter with a discontinuation advice sent to long-term benzodiazepine users in family practice followed by an evaluation consultation offer. The experimental group consisted of 2425 long-term benzodiazepine users, 1707 of whom were addressed by a discontinuation letter and an evaluation consultation offer. The control group consisted of 1821 long-term users. Primary endpoints were the number of prescribed daily dosages (PDD) and the percentage of subjects without prescription (quitters). At 21 months a reduction in benzodiazepine prescription of 26% was observed in the experimental group, versus 9% in the control group (PDD difference = 12.5; 95%-ci: 8.2-16.8). In the experimental group 13% and in the control group 5% of the study completers were benzodiazepine prescription free through the full follow-up period (RR = 2.6; 95%-ci: 2.0-3.4). The percentage of quitters at short-term (6 months) was 24% in the experimental group versus 12% in the control group (RR = 2. 1; 95%-ci: 1.8-2.4). It is concluded that this intervention strategy steadily reduces long-term benzodiazepine use in family practice.
Copyright 2005, Elsevier Science Ireland, Ltd.
Improving screening for alcohol use during pregnancy: The Massachusetts ASAP program.
Kennedy C; Finkelstein N; Hutchins E; Mahoney J. Maternal and Child Health Journal 8(3): 137-147, 2004. (41 refs.)Objective: To motivate prenatal care staff in public and private settings to universally screen of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit. Methods: The ASAP Projects methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital. Results: Across 16 sites 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit. Conclusions: Screening and visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.
Copyright 2004, Springer/Plenum.
Increasing the screening and counseling of adolescents for risky health behaviors: A primary care intervention.
Ozer EM; Adams SH; Lustig JL; Gee S; Garber AK; Gardner LR. Pediatrics 115(4): 960-968, 2005. (37 refs.)Objective. To determine whether a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients, compared with the usual standard of care. Methods. The intervention was conducted in 2 outpatient pediatric clinics; 2 other pediatric clinics in the same health maintenance organization served as comparison sites. The intervention was implemented in 2 phases: first, pediatric primary care providers attended a training workshop (N = 37) to increase screening and counseling of adolescents in the areas of tobacco, alcohol, drugs, sexual behavior, and safety (seatbelt and helmet use). Second, screening and charting tools were integrated into the intervention clinics. Providers in the comparison sites ( N = 39) continued to provide the usual standard of care to their adolescent patients. Adolescent reports were used to assess changes in provider behavior. After a well visit, 13- to 17-year olds ( N = 2628) completed surveys reporting on whether their provider screened and counseled them for risky behavior. Results. Screening and counseling rates increased significantly in each of the 6 areas in the intervention sites, compared with rates of delivery using the usual standard of care. Across the 6 areas combined, the average screening rate increased from 58% to 83%; counseling rates increased from 52% to 78%. There were no significant increases in the comparison sites during the same period. The training component seems to account for most of this increase, with the tools sustaining the effects of the training. Conclusions. The study offers strong support for an intervention to increase clinicians' delivery of preventive services to a wide age range of adolescent patients.
Copyright 2005, American Academy of Pediatrics.