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...on Substance Abuse and Primary Care
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www.ProjectCork.org
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Spring 2006
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Effectiveness of strategies to implement brief alcohol intervention in primary healthcare: A systematic review.
Nilsen P; Aalto M; Bendtsen P; Seppa K. Scandinavian Journal of Primary Health Care 24(1): 5-15, 2006. (47 refs.)
Objective. To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. Key question. To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful? Method. Literature search from Medline, Cinahl, PsychLIT, Cochrane. Setting. Primary healthcare. Material. A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 "non-physicians'' from Europe, the USA, and Australia. Main outcome measures. Material utilization, screening, and brief intervention rates. Answer. Intervention effectiveness ( material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers. Copyright 2006, Scandinavian University Press.
Advice to patients in Swedish primary care regarding alcohol and other lifestyle habits: How patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation.
Johansson K; Bendtsen P; Akerlind I. European Journal of Public Health 15(6): 615-620, 2005. (35 refs.)
Background: Lifestyle advice given by general practitioners (GPs) may be a cost-effective means of health promotion; however, it is not fully put into routine practice. The aim of this study was to explore to what extent GPs' patients expect and receive advice concerning alcohol, tobacco, exercise and diet in relation to sociodemographic characteristics, type of visit and patient satisfaction. Methods: A postal questionnaire was sent to a representative sample (n = 9750) of patients who had consulted GPs in a county in Sweden. The response rate was 69% (n = 6734). Results: Exercise was the most (16%) and alcohol the least (5%) common type of advice. The patients received advice more often than they expected in all areas except alcohol. The patients reported the highest rate of unfulfilled advice expectation and the lowest rate of unexpected advice in the case of alcohol. Male gender, poorer self-rated health and scheduled appointment were independent predictors of all types of advice. Continuity of GP contact was only favourable for exercise and diet advice. The patients who received advice were more satisfied with their visit to the doctor. Conclusions: A tertiary preventive perspective guides GPs' practice of giving advice. Male patients with advanced illnesses are given priority. Women and patients with long-term risk habits are more neglected. The GPs tend to misjudge the expectations and needs of their patients and are too restrained in their counselling practice. Alcohol is the most disregarded area of advice in proportion to the patients' expectations and needs. Copyright 2005, Oxford
Factors that influence adolescent reports of counseling by physicians on risky behavior.
Fairbrother G; Scheinmann R; Osthimer B; Dutton MJ; Newell KA; Fuld J et al. Journal of Adolescent Health 37(6): 467-476, 2005. (29 refs.)
Purpose: To determine factors that affect whether low-income adolescents report that their doctor talked with them about risky behavior. Methods: Random digit-dial survey of low-income adolescents in New York City asking about depression, smoking, alcohol use, and sexual activity and the screening and counseling they received on these risk factors and risks during health visits. Results: Prevalence of counseling by physicians was low, according to adolescent reports, ranging from 17% of adolescents counseled about depression to 52% about sexually transmitted diseases. Older adolescents were more likely than younger to receive counseling about all topics. In bivariate and multivariate models, having the risk factor was strongly associated with physicians counseling for depression (aqjusted [adj.] OR = 4,42;p < 0.001); for sexual activity and counseling about condom use (adj. OR = 4.06; p < 0.01), and birth control (adj. OR = 2.76; p < 0.03). Still, many adolescents at risk had not received counseling. Many adolescents have not had a private and confidential visit with their provider. Having a private and confidential visit was also associated with receipt of counseling. Conclusions: Adolescents are not receiving sufficient counseling about risks and risky behavior, according to their own reports. There is need to improve delivery of counseling and ensure that private and confidential visits arc: provided to youth. Copyright 2005, Society for Adolescent Medicine.
Implementation of brief alcohol intervention in primary health care: Do nurses' and general practitioners' attitudes, skills and knowledge change?
Aalto M; Pekuri P; Seppa K. Drug and Alcohol Review 24(6): 555-558, 2005. (16 refs.)
Brief alcohol intervention reduces heavy drinking, but its implementation has been challenging. The purpose was to evaluate self-reported changes in attitudes, skills and knowledge regarding brief intervention among nurses and general practitioners (GPs) during an implementation project. A questionnaire survey was used before and after the implementation to all nurses and GPs working at the time in the seven primary health-care centres of the city of Tampere, Finland. Several positive changes indicate an increased amount of knowledge regarding brief intervention among the professionals during the implementation. This was found especially among the nurses. The success in increasing the knowledge can also be seen in a decrease of training needs. Instead, attitudes and skills among the professionals did not seem to develop positively. Increasing motivational skills especially seems to be the future challenge. Copyright 2005, Taylor and Francis, Ltd.
Predictors of discontinuation of benzodiazepine prescription after sending a letter to long-term benzodiazepine users in family practice.
Gorgels WJMJ; Oude Voshaar RC; Mol AJJ; van de Lisdonk EH; van Balkom AJLM; Breteler MHM. Family Practice 23(1): 65-72, 2006. (23 refs.)
Background. Predictors of benzodiazepine discontinuation after sending a discontinuation letter by the family practitioner have not been established sufficiently. Objective. To identify predictors of short- and long-term discontinuation of benzodiazepine use and relapse in use after a minimal intervention with a discontinuation letter followed by an offer for an evaluation consultation. Methods. Predictors of benzodiazepine discontinuation and relapse in use were studied by logistic regression analysis and survival analysis within a family practice population of long-term benzodiazepine users (n = 1707) addressed by a discontinuation letter and followed for 21 months. Results. A lower baseline prescription, a shorter duration of use, male gender and use of an agent with a half-life time < 24 hours were predictive of complete discontinuation in the short (6 months) and long term (21 months). Multiple agent use at baseline, use of antidepressants at 6 months and benzodiazepine type (anxiolytic/hypnotic) at baseline predicted relapse. Attendance at an evaluation consultation 3 months after the letter was sent was not predictive of discontinuation or relapse. Conclusions. Amount of baseline use and duration of use are the main determinative characteristics of successful discontinuation. The discontinuation letter intervention is suitable for use with a broad group of long-term benzodiazepine users in family practice and can be used as a first step within a stepped care approach to decrease long-term benzodiazepine use. Copyright 2006, Oxford University Press.
Support for buprenorphine and methadone prescription to heroin-dependent patients among New York City physicians.
Coffin PO; Blaney S; Fuller C; Vadnai L; Miller S; Vlahov D. American Journal of Drug and Alcohol Abuse 32(1): 1-6, 2006. (8 refs.)
Methadone and bilprenorphine are treatments for heroin-dependent patients. Methadone is available through highly-regulated treatment centers while buprenorphine was approved in 2002 for prescription by certified physicians. Just prior to the approval of buprenorphine, we conducted a random postal survey of 770 physicians in New York City to determine willingness to prescribe methadone or buprenorphine for heroin-dependent patients to be picked up at a pharmacy. Among 247 respondents, 36.3% would consider prescribing methadone and 17.9% were unsure, while 25.8% would consider prescribing buprenorphine and 31.8% were unsure. Willingness to prescribe methadone or buprenorphine was associated with more recent year of licensure (p = 0.044; p = 0.033), working in a hospital or clinic as opposed to an office setting (p = 0.009; p = 0.024), and being the director of a clinic or program (p = 0.031; p = 0.008). This preliminary study suggests that a substantial proportion of New York City physicians would prescribe methadone or buprenorphine to heroin-dependent patients. Copyright 2006, Taylor & Francis.
The A-R-T of tobacco use counseling with adolescents: A new office approach.
Spigarelli MG; Heyman RB. Patient Care 39(12): 27-35, 2005. (15 refs.)
This article focuses on practical strategies for working with young people, with application for counseling on any risky behavior. The article is organized around the 5As (ask, advise, assist, assess, and arrange; the 5 Rest (relevance, risks, rewards, roadblocks and repetition); and the 5 Ts (terminate, tend, teach, tune in and talk.) While long term health consequences of smoking such as emphysema, cardiovascular disease and lung cancer are not significant disincentives for the young, social issues such as stained clothing, bad breath, dental problems and cost, can be motivation. Support for the use of nicotine replacement can be drawn from the harm reduction model. Nicotine by itself is safer than the combination of nicotine and other chemical taken in by using tobacco. The 5 "Ts" are related to having an on-going conversation with parent as well as child through all periods of childhood, and to promote prevention in the broadest sense. Terminate refers to the need to terminate all tobacco use during pregnancy to deal with health concerns. "Tend" refers to efforts to keep the child's environment smoke-free. Teach encourages parents to teach their children about the dangers of tobacco use; tune in refers to noting the messages in the media and marketing to which children are exposed. Talk refers to encouraging parent and adolescents to continue to talk about not using tobacco. The authors also consider the application of motivational interviewing, again providing useful examples. Copyright 2005, Medical Economics.
Ryan White Title I survey: Services for HIV-positive substance users.
Tobias C; Wood S; Drainoni ML. AIDS Patient Care and STDS 20(1): 58-67, 2006. (12 refs.)
People living with HIV/AIDS who are also substance users need primary health care, substance abuse treatment, and support services. They also require care delivery strategies that are comprehensive and innovative. Forty-three of 51 Ryan White Care Act Title I grantees funding 197 substance abuse treatment agencies in the United States participated in this study. Grantees were surveyed to determine (1) use of Title I funding to provide services for HIV-positive substance users, (2) the types of substance abuse services provided, (3) strengths and weaknesses of different metropolitan substance abuse service delivery systems, (4) sources of information used to assess the needs of substance users, (5) gaps in knowledge about substance users and their service needs, and (6) examples of successful strategies within the eligible metropolitan areas. The results of the study demonstrate that most grantees use Title I funds to support some form of substance abuse treatment for people with HIV; however, many do not use the funds to address the barriers to care that they identified. Lack of provider knowledge, expertise, and awareness, were cited as important barriers to care by a majority of the grantees. The availability of harm reduction approaches to care is an area in which there is wide variation. Several Title I programs have supported innovative programs for HIV positive substance users that may be used elsewhere as program models. It is important to find ways to incorporate these issues into the needs assessment and service prioritization process. Copyright 2006, Mary Ann Liebert, Inc.
The feasibility of connecting physician offices to a state-level tobacco quit line.
Bentz CJ; Bayley KB; Bonin KE; Fleming L; Hollis JF; McAfee T. American Journal of Preventive Medicine 30(1): 31-37, 2006. (14 refs.)
Background: Telephone counseling for tobacco cessation is an effective and evidence-based approach to address tobacco use. The wide dissemination of region- and state-level quit lines has been a major goal for public health agencies. However, connecting patients in primary care settings to state-level quit lines has not been evaluated. Methods: Observational study, describing two methods (fax referral and providing a brochure) to connect private physician offices with a state-level quit line in Oregon. This study describes the resources required to create a clinical pathway for the 5A's in primary care (ask, advise, assess, assist, and arrange) using a state-level telephone quit line as an intervention for cessation in primary care clinics sharing a common electronic medical record system, focusing on the costs and generalizability of this approach. Results: Of the 15,662 smokers identified in 19 primary care clinics, 745 patients were referred to the Oregon Tobacco Quit Line during the study period. The program cost in the first year was $15 to $22 per patient connected with the quit line; in subsequent years, the cost decreased to $4 to $6 per quit-line connection. Conclusions: Connecting private physician offices to a state-level quit line is feasible, can be accomplished at low cost with minimal use of resources, and may be cost effective. Regional, state, and local tobacco quit lines should consider a physician office "quit-line connection" as a practical approach to increase utilization. Copyright 2006, Elsevier Science Inc.
Do mechanisms that link addiction treatment patients to primary care influence subsequent utilization of emergency and hospital care?
Friedmann PD; Hendrickson JC; Gerstein DR; Zhang ZW; Stein MD. Medical Care 44(1): 8-15, 2006. (40 refs.)
Background: Patients with drug use disorders are heavy users of emergency department (ED) and inpatient hospital care. This study examines whether formal mechanisms to link addiction treatment patients to primary medical care, either directly on site or by off-site referral-when compared with an absence of said mechanisms-might reduce these patients' use of ED and hospital services after substance abuse treatment. Methods: We used longitudinal data from 6 methadone maintenance programs with 232 patients, 24 outpatient nomnethadone programs with 1202 patients, and 14 long-term residential programs with 679 patients in the National Treatment Improvement Evaluation Study. Multivariate logistic models controlling for health status and medical service utilization before treatment examined whether provision of medical services on- or off-site during treatment linkage led to reduced use of ED and hospital services in the year after treatment compared with no such provision. Results: On-site delivery of primary care reduced subsequent ED and hospital use among patients in methadone maintenance and long-term residential compared with the nonlinkage condition but not in outpatient nomnethadone programs. Off-site referral for medical care reduced subsequent ED visits but not hospitalizations in long-term residential programs. Conclusions: These findings suggest that for some treatment modalities, stronger primary care linkage mechanisms decrease subsequent utilization of expensive ED and hospital services. Future study should examine the cost implications of these strong linkage mechanisms and ways to strengthen linkages to off-site medical care. Copyright 2006, Lippincott Williams & Wilkins.
Health care provider advice and risk factors associated with alcohol consumption following pregnancy recognition.
O'Connor MJ; Whaley SE. Journal of Studies on Alcohol 67(1): 22-31, 2006. (61 refs.)
Objective: This study examined the extent to which pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were counseled by their health care providers to stop drinking alcohol during pregnancy A second purpose was to identify characteristics associated with alcohol consumption postrecognition of pregnancy. Method: The sample consisted of 279 women who continued to drink after learning they were pregnant. Measures of provider advice on alcohol consumption, demographic characteristics caffeine intake, smoking, other drug use, alcohol risk (using the TWEAK scale), and depressive symptoms on the Center for Epidemiological Studies Depression Scale (CES-D) were collected. Results: Sixty-two percent of women had significantly high TWEAK scores, and 60% scored within the clinical range for depression (CES-D >= 16). Sixty percent of sample women had been advised by their care providers not to drink alcohol during pregnancy. Women who were most likely to receive advice were black non-Hispanic and Hispanic, were Spanish speaking, were less educated, were on public assistance, and had a higher number of alcohol-related risk behaviors. Advanced age, public assistance, caffeine use, smoking, and elevated TWEAK and CES-D scores predicted elevations in alcohol consumption rates. Conclusions: Although advice to stop drinking during pregnancy was provided to 60% of this sample, women continued to drink following pregnancy recognition, with alcohol consumption rates highly associated with sociodemographic and psychological factors, namely maternal depression. Because elevations in alcohol consumption during pregnancy are associated with poorer developmental outcomes for children, further efforts are needed to better address social and mental health factors that influence consumption. Copyright 2006, Alcohol Research Documentation, Inc.
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