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...on Substance Abuse and Primary Care
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www.ProjectCork.org
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Fall 2006
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Do primary care physicians' own AUDIT scores predict their use of brief alcohol intervention? A cross-sectional survey.
Aalto M; Hyvonen S; Seppa K. Drug and Alcohol Dependence 83(2): 169-173, 2006. (15 refs.)
Background: To define whether the Alcohol Use Disorders Identification Test (AUDIT) scores of primary care physicians themselves predict their willingness to use brief alcohol intervention. Methods: Cross-sectional self-administered questionnaire survey to all 3193 physicians providing primary health care in Finland. The response rate was 1909 (59.8%). Odds ratios from multinomial regression analysis were calculated for self-reported frequency (never, occasionally or regularly) of conducting brief interventions by physicians with AUDIT scores of 0-1, 2, 3, 4, 5-7 or >= 8. Results: The prevalence of heavy drinkers based on AUDIT score (>= 8) was 14.5% among all physicians, 7.0% among females and 27.0% among males. Of the respondents 9.4% reported doing brief intervention regularly and 50.0% occasionally. AUDIT scores did not significantly predict either regular or occasional use of brief intervention. Instead, some other independent predictors for more frequent use of brief intervention were found. These included having a specialist licence in general practice or occupational health care and the location of the practice, but not gender or age. Conclusions: The present results indicate that in general heavy drinking among primary care physicians do not explain the low frequency with which brief intervention is used in primary health care. Copyright 2006, Elsevier Science.
A low-cost, sustainable intervention for drinking reduction in the HIV primary care setting.
Aharonovich E; Hatzenbuehler ML; Johnston B; O'Leary A; Morgenstern J; Wainberg ML et al. AIDS Care 18(6): 561-568, 2006. (54 refs.)
Excess drinking poses multiple substantial health risks to HIV-infected individuals. However, no published intervention studies have focused on drinking reduction as the main outcome in HIV primary care patients. An intervention in this setting must place minimal demands on pressured staff and resources. This pilot study tested such an intervention, which consisted of brief Motivational Interviewing (MI) and HealthCall, an automated daily telephone self-monitoring system based on Interactive Voice Response (IVR), designed to extend and enhance the effects of brief MI. Thirty-one patients entered the study, received a 30-minute MI and were instructed in daily use of the IVR system. They received graphical feedback on their daily drinking from the HealthCall database after 30 days. A statistically significant decrease in drinking was found over time, both as reported in daily IVR calls (beta = -0.01, se 0.01, p = .03) and in follow-up interviews (beta = -0.04, se 0.12, p = 02) at 60 days. The proportion of daily calls made supported the feasibility of the intervention. The results indicate that HealthCall is acceptable to a disadvantaged HIV patient population, and preliminary data support the efficacy of this intervention in reducing harmful drinking among HIV primary care patients. Copyright 2006, Taylor & Francis.
Cost-effectiveness of pharmacotherapies for nicotine dependence in primary care settings: A multinational comparison.
Cornuz J; Gilbert A; Pinget C; McDonald P; Slama K; Salto E et al. Tobacco Control 15(3): 152-159, 2006. (47 refs.)
Objective: To estimate the incremental cost-effectiveness of the first-line pharmacotherapies ( nicotine gum, patch, spray, inhaler, and bupropion) for smoking cessation across six Western countries - Canada, France, Spain, Switzerland, the United States, and the United Kingdom. Design and study population: A Markov-chain cohort model to simulate two cohorts of smokers: ( 1) a reference cohort given brief cessation counselling by a general practitioner ( GP); ( 2) a treatment cohort given counselling plus pharmacotherapy. Effectiveness expressed as odds ratios for quitting associated with pharmacotherapies. Costs based on the additional physician time required and retail prices of the medications. Interventions: Addition of each first-line pharmacotherapy to GP cessation counselling. Main outcome measures: Cost per life-year saved associated with pharmacotherapies. Results: The cost per life-year saved for counselling only ranged from US$190 in Spain to $773 in the UK for men, and from $288 in Spain to $1168 in the UK for women. The incremental cost per life-year saved for gum ranged from $2230 for men in Spain to $7643 for women in the US; for patch from $1758 for men in Spain to $5131 for women in the UK; for spray from $1935 for men in Spain to $7969 for women in the US; for inhaler from $3480 for men in Switzerland to $8700 for women in France; and for bupropion from $792 for men in Canada to $2922 for women in the US. In sensitivity analysis, changes in discount rate, treatment effectiveness, and natural quit rate had the strongest influences on cost-effectiveness. Conclu-sions: The cost-effectiveness of the pharmacotherapies varied significantly across the six study countries, however, in each case, the results would be considered favourable as compared to other common preventive pharmacotherapies. Copyright 2006, BMJ Publishing Group.
Identifying hazardous alcohol consumption during pregnancy: Implementing a research-based model in real life.
Goransson M; Magnusson A; Heilig M. Acta Obstetricia et Gynecologica Scandinavica 85(6): 657-662, 2006. (31 refs.)
Aims. It has been repeatedly demonstrated that hazardous alcohol use during pregnancy is rarely detected in regular antenatal care, and that detection can be markedly improved using systematic screening. A major challenge is to translate research-based strategies into regular antenatal care. Here, we examined whether a screening strategy using the Alcohol Use Disorder Test (AUDIT) and time-line follow-back (TLFB) could be implemented under naturalistic conditions and within available resources, and whether it would improve detection to the extent previously shown in a research context. Methods. Regular midwives at a large antenatal care clinic were randomized to receive brief training and then implement AUDIT and TLFB ("intervention"); or to a waiting-list control group continuing to deliver regular care ("control"). In the intervention condition, AUDIT was used to collect data about alcohol use during the year preceding pregnancy, and TLFB to assess actual consumption during the first trimester. Data were collected from new admissions over 6 months. Results. Drop out was higher among patients of the intervention group than control midwives, 14% (23/162) versus 0% (0/153), and p < 0.0001. A one-day training session combined with continuous expert support was sufficient to implement systematic screening with AUDIT and TLFB largely within resources of regular antenatal care. The use of these instruments identified patients with hazardous consumption during the year preceding pregnancy i.e. AUDIT score 6 or higher (17%, 23/139), and patients with ongoing consumption exceeding 70 g/week and/or binge consumption according to TLFB (17%, 24/139), to a significantly higher degree than regular antenatal screening (0/162). The AUDIT- and TLFB-positive populations overlapped partially, with 36/139 subjects screening positive with either of the instrument and 11/139 were positive for both. Conclusions. We confirm previous findings that alcohol use during pregnancy is more extensive in Sweden than has generally been realized. Systematic screening using AUDIT and TLFB detects hazardous use in a manner which regular antenatal care does not. This remains true under naturalistic conditions, following minimal training of regular antenatal care staff, and can be achieved with minimal resources. The proposed strategy appears attractive for broad implementation. Copyright 2006, Munksgaard Int. Publ, Ltd.
Best practices for smoking cessation in pregnancy: Do obstetrician/gynecologists use them in practice?
Jordan TR; Dake JA; Price JH. Journal of Women's Health 15(4): 400-411, 2006. (32 refs.)
Objective: To assess Ohio obstetrician/gynecologists' perceptions and use of the 5As method of smoking cessation ( ask, advise, assess, assist, and arrange) with pregnant patients who smoke. Methods: A three-wave mailing procedure was used with a statewide random sample of obstetrician/ gynecologists who responded to a valid and reliable 31-item questionnaire. Results: Regarding the 5As method of smoking cessation, almost all (98%) asked their pregnant patients about smoking, but fewer respondents engaged in advising (66%), assessing (42%), assisting (29%), and arranging for follow-up visits or referrals (6%). Higher efficacy expectations were associated with greater use of the 5As method ( r = 0.52, p < 0.001). A majority believed that two cessation activities would result in smoking cessation in pregnant smokers: explaining the dangers of smoking (65%) and referring pregnant smokers to smoking cessation programs (57%). However, 26% of physicians reported that they were "slightly confident" or "not confident at all" in their ability to refer pregnant smokers to such programs, and 6% of physicians reported always providing smoking cessation referrals. A significant proportion of respondents believed that prenatal smoking would not cause severe effects for the unborn child but would likely lead to moderate (46%) or minor (3%) health effects. Conclusion: Obstetrician/gynecologists face many competing demands for their time and energy, yet 62% believed smoking cessation advice would be of significant value. Physicians with higher levels of efficacy expectations reported significantly greater use of the 5 As. Future research should explore ways to facilitate obstetrician/ gynecologists' use of the 5As method. Copyright 2006, Mary Ann Liebert.
Factors predicting unmet health services needs among incarcerated substance users.
Narevic E; Garrity TF; Schoenberg NE; Hiller ML; Webster JM; Leukefeld CG et al. Substance Use & Misuse 41(8): 1077-1094, 2006. (37 refs.)
Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998-1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed. Copyright 2006, Marcel Dekker.
Teaching about substance abuse with objective structured clinical exams.
Parish SJ; Ramaswamy M; Stein MR; Kachur EK; Arnsten JH. Journal of General Internal Medicine 21(5): 453-459, 2006. (44 refs.)
Background: Although residents commonly manage substance abuse disorders, optimal approaches to teaching these specialized interviewing and intervention skills are unknown. Objective: We developed a Substance Abuse Objective Structured Clinical Exam (OSCE) to teach addiction medicine competencies using immediate feedback. In this study we evaluated OSCE performance, examined associations between performance and self-assessed interest and competence in substance abuse, and assessed learning during the OSCE. Design: Five-station OSCE, including different substance abuse disorders and readiness to change stages, administered during postgraduate year-3 ambulatory rotations for 2 years. Participants: One hundred and thirty-one internal and family medicine residents. Measurements: Faculty and standardized patients (SPs) assessed residents' general communication, assessment, management, and global skills using 4-point scales. Residents completed a pre-OSCE survey of experience, interest and competence in substance abuse, and a post-OSCE survey evaluating its educa-tional value. Learning during the OSCE was also assessed by measuring performance improvement from the first to the final OSCE station. Results: Residents performed better (P <.001) in general communication (mean +/- SD across stations=3.12 +/- 0.35) than assessment (2.65 +/- 0.32) or management (2.58 +/- 0.44), and overall ratings were lowest in the contemplative alcohol abuse station (2.50 +/- 0.83). Performance was not associated with residents' self-assessed interest or competence. Perceived educational value of the OSCE was high, and feedback improved subsequent performance. Conclusions: Although internal and family medicine residents require additional training in specialized substance abuse skills, immediate feedback provided during an OSCE helped teach needed skills for assessing and managing substance abuse disorders. Copyright 2006, Blackwell Science Ltd.
Primary care validation of a single screening question for drinkers.
Seale JP; Boltri JM; Shellenberger S; Velasquez MM; Cornelius M; Guyinn M et al. Journal of Studies on Alcohol 67(5): 778-784, 2006. (31 refs.)
Objective: The aim of this study was to conduct a primary care validation study of a single screening question for alcohol misuse ("When was the last time you had more than X drinks in 1 day?," where X was four for women and X was five for men), which was previously validated in a study conducted in emergency departments. Method: This cross-sectional study was accomplished by interviewing 625 male and female adult drinkers who presented to five southeastern primary care practices. Patients answered the single question (coded as within 3 months, within 12 months, ever, or never), Alcohol Use Disorders Identification Test (AUDIT), and AUDIT consumption questions (AUDIT-C). Alcohol misuse was defined as either at-risk drinking, identified by a 29-day Timeline Followback interview or a current (past-year) alcohol-use disorder by DSM-IV criteria, or both. Results: Among 625 drinkers interviewed, 25.6% were at-risk drinkers, 21.7% had a current alcohol-use disorder, and 35.2% had either or both conditions. Considering "within the last 3 months" as positive, the sensitivity of the single question was 80% and the specificity was 74%. Chi-square analyses revealed similar sensitivity across ethnic and gender groups; however, specificity was higher in women and whites (p = .0187 and .0421, respectively). Considering "within the last 12 months" as positive increased the question's sensitivity, especially for those with alcohol-use disorders. The area under the receiver operating characteristic curve of the single alcohol screening question (0.79) was slightly lower than for the AUDIT and AUDIT-C, but sensitivity and specificity were similar. Conclusions: A single question about the last episode of heavy drinking is a sensitive, time-efficient screening instrument that shows promise for increasing alcohol screening in primary care practices. Copyright 2006, Alcohol Research Documentation, Inc.
Providing opioid substitution treatment to Indigenous heroin users within a community health service setting in Adelaide.
Williams N; Nasir R; Smither G; Troon S. Drug and Alcohol Review 25(3): 227-232, 2006. (18 refs.)
In the late 1990s there was major concern regarding heroin use among the Nunga community in Adelaide. [Nunga is a generic term used for Aboriginal people from South Australia, similar to Koori's from Victoria and Nyungars from south-western Australia.] Heroin use was so common that community members reported that most families were affected by it in some way. There were few Nunga specific services provided, and those mainstream services available were not seen as culturally appropriate or for other reasons were difficult to access. In response to this, the Parks Community Health Centre, together with the Drug and Alcohol Services Council, and with the assistance of Nunkuwarrin Yunti Aboriginal Health Service [Adelaide's Aboriginal Community Controlled Health Service, based in the City Centre], commenced a programme offering treatment interventions for Nunga heroin users. The 'Way Out' Program commenced in March 1999. It is multi-faceted and includes an opioid substitution programme which is attracting and maintaining Nunga clients in greater numbers than ever before in South Australia. The programme utilises networks through-out the Nunga community and in recent years has formed a strong working partnership with the Aboriginal Kinship Program, that works with families and individuals seeking support for family members in relation to illicit drug issues by providing support, referral, follow-up and advocacy services. The 'Way Out' Program is making essential treatment services available to Aboriginal people using heroin. This article provides an overview of the programme. Copyright 2006, Taylor & Francis.
An interdisciplinary faculty development model for the prevention and treatment of alcohol use disorders.
Manwell LB; Pfeifer J; Stauffacher EA. Alcoholism: Clinical and Experimental Research 30(8): 1393-1399, 2006. (28 refs.)
The skills of faculty working in health fields are inadequate to meet the needs of those adversely affected by alcohol. This project was designed to increase the teaching, clinical, and research activities of faculty from multiple disciplines at the university level. The faculty development model included two 2-day skills-based courses held 6 months apart, precourse and postcourse evaluations, active mentoring, and development of a specific work plan for each participant. The educational model utilized skills-based courses previously developed for full-time clinical/teaching medical faculty with limited time and resources. A total of 153 participants at 6 locations completed the courses; 131 completed the 6-month follow-up interview. Sixty-four designed teaching, clinical, or research projects during the 6-month period between the first and second courses. Precourse versus postcourse clinical scores from standardized patient encounters showed highly significant improvements in screening, brief intervention, and motivational interviewing skills (p < 0.001). At the 6-month follow-up interview, 61% of the participants reported teaching on alcohol, tobacco, or drug problems; 49% reported clinical activities in this area; 36% reported conducting research; 10% had submitted manuscripts for publication; 12% had submitted grant applications; and 32% percent had sought additional AODA training. Participants gave high scores to all components of the faculty development model; 81% would repeat the training and 98% would recommend the program to colleagues. This cost-effective faculty development program can serve as a model to increase educational programs on substance abuse at public universities, increase faculty research activities in the alcohol area, and increase clinical programs in university hospitals. Copyright 2006, Research Society on Alcoholism.
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