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...on Substance Abuse and Primary Care
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www.ProjectCork.org
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Winter 2005
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Anabolic steroid users' attitudes towards physicians.
Pope HG; Kanayama G; Ionescu-Pioggia M; Hudson JI. Addiction 99(9): 1189-1194, 2004. (31 refs.)
Aims To assess anabolic-androgenic steroid (AAS) users' trust in the knowledge and advice of physicians. Design: Interviews of AAS users and non-users. Setting: Research offices. Participants: Eighty weight-lifters (43 AAS users, 37 non-users) recruited by advertisement in Massachusetts and Florida, USA. Measurements: Personal interviews and questionnaire responses, including subjects' ratings of physicians' knowledge regarding various health- and drug-related topics. AAS users also rated their level of trust in various sources of information about AAS. Findings: Both groups of subjects gave physicians high ratings on knowledge about general health, cigarette smoking, alcohol, and conventional illicit drugs, but gave physicians markedly and significantly lower ratings on knowledge about AAS. When rating sources of information on AAS, users scored physicians as no more reliable than their friends, Internet sites, or the person(s) who sold them the steroids. Forty percent of users trusted information on AAS from their drug dealers at least as much as information from any physician that they had seen, and 56% had never revealed their AAS use to any physician. Conclusion: AAS users show little trust in physicians' knowledge about AAS, and often do not disclose their AAS use to physicians. These attitudes compromise physicians' ability to educate or treat AAS users. Physicians can respond to these problems by learning more about AAS and by maintaining a high index of suspicion when evaluating athletic male patients. Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs.
Zyban for smoking cessation in a general practice setting: The response to an invitation to make a quit attempt.
Johnstone E; Hey K; Drury M; Roberts S; Welch S; Walton R. Addiction Biology 9(3-4): 227 -232, 2004. (14 refs.)
The objective of this study was to assess the feasibility and success of Zyban as part of a moderately supported smoking cessation programme within UK general practice. Treatment was offered to 479 moderately dependent smokers ( smoking 15 or more cigarettes per day) who had never used Zyban, and who had taken part in a previous NRT trial ( the PATCH study). Main outcome measures were point prevalence and continuous abstinence from smoking at 6 and at 12 months. Two hundred and forty were excluded because of medical reasons or prescribing contraindication. Of the remainder (n = 239) only 54 (23%) made an active quit attempt. Thirty percent (16/54) were abstinent at six months, and 22% (12/54) at 12 months ( biochemically validated point prevalence rates). Age, socio-economic status, nicotine dependence, and genetic pro. le appeared to have little impact on success rates, but male quit-attempters were significantly more successful than female ( 40% vs. 10% at 12 months, p<0.05). In conclusion, a real-world smoking cessation programme using Zyban with moderate support within a general practice setting may achieve satisfactory quit rates without widening existing disparities in cessation. Copyright 2004, Carfax, Ltd.
Adolescents in mid-sized and rural communities: Foregone care, perceived barriers, and risk factors.
Elliott BA; Larson JT. Journal of Adolescent Health 35(4): 303 -309, 2004. (18 refs.)
Purpose: To investigate the perceived health care needs, foregone care, barriers to care, and associated risk factors in a non-urban population of adolescents. Methods: Tenth-grade students attending school and 15-17-year-old youth not attending school in a Midwestern county were surveyed or interviewed. Eighty-six percent provided usable data (n = 1948, 134 of whom were not in school). Nine focus groups (71 participants; 28 were not in school) were conducted in follow-up. Quantitative analysis included descriptive statistics, factor analysis, and logistic regression. Qualitative analysis of taped focus groups identified themes and interpreted findings. Results: Although 91% had seen a physician in the past 2 years, 44% reported foregoing needed care in the last year. Barriers for specific health needs were: cost of care and lack of insurance coverage for injuries and illnesses; lack of knowledge, distrust, and stigma for depression,embarrassment and transportation for birth control and sexually transmitted infections (STIs); and not knowing where or how to access care for drug and alcohol use. Youth most likely to have foregone care included those involved with dangerous activities under peer pressure (1.8, Cl: 1.44-2.13), sexual intercourse (1.4, Cl: 1.25-1.67), marijuana use (1.4, CI: 1.17-1.67), anticipating parenthood before age 20 years (1.2, Cl: 1.04-1.33), male gender (2.5, CI: 1.89-2.86) and perceiving good health (1.7, CI: 1.45-1.85). Conclusions: Nearly half of this non-urban population (both in and out of school) reported foregoing needed care in the last year. The barriers to care include lack of information, lack of access, poor insurance cover-age, parenting issues, and concern about confid-entiality. Copyright 2004, Society for Adolescent Medicine.
Biochemical alcohol screening in primary health care.
Miller PM; Anton RF. Addictive Behaviors 29(7 (Special Issue)): 1427-1437, 2004. (48 refs.)
Alcohol biomarkers such as carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) have significant potential for enhancing the quality of medical treatment in primary health care settings. Recent studies demonstrate that these laboratory tests can help the general practitioner in several ways. First, CDT and GGT can detect current heavy drinking in primary care patients with a fair degree of sensitivity (60% to 70%), with CDT being more specific (90%). When combined with self-report tests, they can provide a clinically useful alcohol screening battery. Second, elevated CDT and GGT levels have been correlated with specific alcohol-sensitive diseases (e.g., hypertension) and, as such, can serve as risk indicators for those diseases. Third, alcohol biomarkers have proven to be useful in monitoring the effectiveness of brief alcohol interventions with medical patients. Unfortunately, preliminary findings indicate that physicians have little knowledge of current biomarker research as applied to primary health care. Translational studies are needed on methods to facilitate knowledge and use of alcohol biomarkers by general practitioners. Copyright 2004, Elsevier Science.
Dealing with the parent whose judgment is impaired by alcohol or drugs: Legal and ethical considerations.
Fraser JJ; Mcabee GN; Commission on Medical Liability. Pediatrics 114(3): 869-873, 2004. (16 refs.)
An estimated 11 to 17.5 million children are being raised by a substance-abusing parent or guardian. The importance of this statistic is undeniable, particularly when a patient is brought to a pediatric office by a parent or guardian exhibiting symptoms of judgment impairment. Although the physician-patient relation-ship exists between the pediatrician and the minor patient, other obligations ( some perceived and some real) should be considered as well. In managing encounters with impaired parents who may become disruptive or dangerous, pediatricians should be aware of their responsibilities before acting. In addition to fulfilling the duty involved with an established physician-patient relationship, the pediatrician should take reasonable care to safeguard patient confid-entiality; protect the safety of the patient and other patients, visitors, and employees; and comply with reporting mandates. This clinical report identifies and discusses the legal and ethical concepts related to these circumstances. The report offers implementation suggestions when establishing anticipatory office procedures and training programs for staff on what to do ( and not do) in such situations to maximize the patient's wellbeing and safety and minimize the liability of the pediatrician. Copyright 2004, American Academy of Pediatrics.
A critical review of caffeine withdrawal: Empirical validation of symptoms and signs, incidence, severity, and associated features. (review).
Juliano LM; Griffiths RR. Psychopharmacology 176(1): 1-29, 2004. (139 refs.)
Rationale: Although reports of caffeine withdraw-al in the medical literature date back more than 170 years, the most rigorous experimental investi-gations of the phenomenon have been conducted only recently. Objectives: The purpose of this paper is to provide a comprehensive review and analysis of the literature regarding human caffeine withdrawal to empirically validate spec-ific symptoms and signs, and to appraise important features of the syndrome. Methods: A literature search identified 57 experimental and 9 survey studies on caffeine withdrawal that met inclusion criteria. The methodological features of each study were examined to assess the validity of the effects. Results: Of 49 symptom categories identified, the following 10 fulfilled validity criteria: headache, fatigue, decreased ener-gy/activeness, decreased alertness, drowsiness, decreased contentedness, depressed mood, difficulty concentrating, irritability, and foggy/not clearheaded. In addition, flu-like symptoms, nausea/vomiting, and muscle pain/stiffness were judged likely to represent valid symptom categories. In experimental studies, the incidence of headache was 50% and the incidence of clinically significant distress or functional impairment was 13%. Typically, onset of symptoms occurred 12-24 h after abstinence, with peak intensity at 20-51 h, and for a duration of 2-9 days. In general, the incidence or severity of symptoms increased with increases in daily dose; abstinence from doses as low as 100 mg/day produced symptoms. Research is reviewed indicating that expectancies are not a prime determinant of caffeine withdrawal and that avoidance of withdrawal symptoms plays a central role in habitual caffeine consumption. Conclusions: The caffeine-withdrawal syndrome has been well characterized and there is sufficient empirical evidence to warrant inclusion of caffeine withdrawal as a disorder in the DSM and revision of diagnostic criteria in the ICD. Copyright 2004, Springer.
Adolescent smoking cessation. (review).
Camenga DR; Klein JD. Current Opinion in Pediatrics 16(4): 368-372, 2004. (38 refs.)
Purpose of review: Approximately 25% of high school students report current cigarette use, 85% of adolescents think about quitting, and around 80% of current smokers made a quit attempt in the past year. This review analyzes recent additions to the adolescent smoking cessation literature from June 1, 2003 to May 1, 2003. Recent findings Adolescent attitudes toward smoking cessation are largely affected by their smoking history. Youth cessation interventions largely focus on behavioral interventions, and research concerning these interventions has yielded mixed results. Little data exist about the effectiveness of nicotine replacement therapy in adolescents, but there is growing evidence that youth use this pharmacotherapy. Recent research has explored the use of nicotine replacement therapy as an adjunct for enhanced smoking reduction in adults, and future research may focus on this tactic for youth as well. Internet cessation adjuncts and telephone quit lines also serve as future frontiers for adolescent smoking cessation research. Summary Information concerning adolescent smoking behaviors, effective interventions, and smoking cessation therapy continue to grow and provide data that improve our understanding of adolescent smoking cessation. Although we cannot directly extrapolate the adult findings to this population, adult cessation research continues to inform future adolescent cessation efforts. Copyright 2004, Lippincott, Williams & Wilkins.
Assessing multiple risk behaviors in primary care: Screening issues and related concepts. (review).
Babor TF; Sciamanna CN; Pronk NP. American Journal of Preventive Medicine 27(2): Suppl. S, 2004. (86 refs.)
The concept of behavioral risk refers to health behaviors that increase the likelihood of a variety of illness conditions. With increased scientific research, it has become clear that this concept is useful in understanding the linkage between behavior and health. This paper reviews scientific, conceptual, and practical issues related to the identification of health risk behaviors in primary care. It includes both a literature review and an analysis of the feasibility of screening and health risk appraisal from a public health perspective, giving special attention to four behavioral risk factors: cigarette smoking, alcohol misuse, physi-cal inactivity, and unhealthy diet. The review indicates that there are a wide variety of accept-able screening tests that can be used for population screening programs, and a large number of health risk appraisal instruments to employ in medical and work settings where preventive health services are available. Given the variety of available assessment procedures, the choice of a given instrument will depend on the target population, the purpose of the program, the time available for assessment, and a number of other practical considerations, such as cost. Multiple risk factor screening is feasible, but there is no single instrument or procedure that is optimal for all risk factors or populations. Based on the results of this review, the specific test or combination of tests is less important than the use of screening to make both patients and healthcare providers more aware of the critical importance of monitoring behavioral risk factors on a routine basis. We conclude that while further research and development work needs to be done, sufficient progress has been made to warrant a more ambitious effort that would bring behavioral risk factor screening into the mainstream of preventive medicine and public health. Copyright 2004, Elsevier Science Inc.
Choosing a behavioral therapy platform for pharmacotherapy of substance users. (review).
Carroll KM; Kosten TR; Rounsaville BJ. Drug and Alcohol Dependence 75(2): 123-134, 2004. (114 refs.)
Behavioral therapy platforms have become virtual requirements in pharmacotherapy trials due to their utility in reducing noise variability, preventing differential medication adherence and protocol attrition, enhancing statistical power and addressing ethical issues in placebo-controlled trials. Selecting an appropriate behavioral platform for a particular trial requires study-specific tailoring, taking into account both the stage of development of the medication being evaluated, as well as the specific strengths and weaknesses of a broad array of available empirically supported behavioral therapies and the range of their possible targets (e.g., enhancing medication adherence, preventing attrition, addressing co-morbid problems, fostering abstinence, and targeting specific weaknesses of the pharmacologic agent). Choosing a suitable behavioral platform also requires consideration of the characteristics of the population to be treated, stage of scientific knowledge regarding the medication's effects, appropriate balance of internal and external validity, and consideration of potential ceiling effects. Available manualized behavioral treatments are reviewed, noting their strengths and limitations as behavioral therapy platforms for pharmacotherapy trials and as potential concomitant therapies in clinical practice. Copyright 2004, Elsevier Science.
Consensus statement on office-based treatment of opioid dependence using buprenorphine.
Fiellin DA; Kleber H; Trumble-Hejduk JG; McLellan AT; Kosten TR. Journal of Substance Abuse Treatment 27(2): 153-159, 2004. (38 refs.)
Buprenorphine and buprenorphine/naloxone (BUP) are newly approved for office-based treatment of opioid dependence. Federal and non-federal regulatory and monitoring agencies, national and international researchers, national professional organizations, researchers involved in monitoring, opioid treatment programs and the pharmaceutical industry met to synthesize and disseminate practical information to guide training, practice, monitoring, regulation and evaluation efforts with these medications. We performed a review of the literature, training curricula and practice guidelines and commissioned manuscripts describing recently completed, or still in progress, studies or field experiences with BUP treatment. A consensus process generated fifteen statements: (1) The federal government should collect baseline data on opioid-related deaths and morbidity to assess the effect of BUP on public health, (2) the patient limit for group practices should apply to individual physicians rather than group practices, (3 and 4) telephone and Internet-based physician and pharmacist support is needed, (5) clinicians who provide psychosocial services to opioid dependent patients should be informed of the role of BUP, (6) opioid-dependent patients should be instructed to present for induction in mild withdrawal, (7) the existing Center for Substance Abuse Treatment guidelines provide a reasonable induction protocol, (8) physicians should be prepared to use ancillary medications with BUP induction, (9) a physician or nurse must be available to the patient during the induction period, (10) concurrent counseling and support services are necessary, (11) detoxification without appropriate followup addiction treatment leads to rapid relapse and is not as effective as maintenance, (12) pregnant opioid-dependent women should be treated using good clinical practice including specialist addiction care and prenatal care, (13) BUP induction and withdrawal treatment may benefit from different designations for payment, (14) take-home medication options should be tailored to patients' needs, (15) there is a need for clinical and policy research in unique patient populations. Copyright 2004, Elsevier Science.
Motivational enhancement and other brief interventions for adolescent substance abuse: foundations, applications and evaluations.
Tevyaw TO; Monti PM. Addiction 99(Supplement 2): 63-75, 2004. (94 refs.)
Aims: To present a comprehensive review of the use of motivational enhancement and other brief interventions for substance use in adolescents. Methods: In this paper, we review the major theoretical foundations and influences of brief interventions (including motivational interview-ing), consider developmental issues in its application for adolescents, discuss methodology-ical issues in the design and implementation of brief interventions, including the assessment of treatment fidelity, evaluate and interpret the latest findings on brief interventions for adolescents and young people and discuss the issue of translating and exporting effective research into practice. Findings: Results from recent clinical trials using motivational interventions indicate that these approaches result in decreases in substance-related negative consequences and problems, decrements in substance use and increased treatment engagement, with results particularly strong for those with heavier substance use patterns and/or less motivation to change. Conclusion: While results are promising, more research is needed to examine the essential elements of motivational interventions, for whom they work best, and their impact on developmental transitions during abstinence. Copyright 2004, Society for the Study of Addiction to Alcohol and Other Drugs.
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