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...on Substance Abuse and Primary Care
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www.ProjectCork.org
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Summer 2006
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Health promotion in older adults: Evidence-based smoking cessation programs for use in primary care settings.
Abdullah ASM; Simon JL. Geriatrics 61(3): 30-34, 2006. (31 refs.)
Tobacco dependency is a growing problem among older adults. Given the addictive nature of tobacco use, smokers need a multifactorial treatment program to help stop smoking. Health care professionals can play a pivotal role in the promotion of a smoking cessation treatment program to people of all ages, including the elderly. This paper presents important evidence that smoking cessation services for the elderly are effective, and describes how primary care physicians can support elderly people quit smoking. Copyright 2006, CIBA.
Need to educate primary caregivers about the risk factor profile of smokeless tobacco users.
Accortt NA; Waterbor JW; Beall C; Howard G; Brooks CM. Journal of Cancer Education 20(4): 222-228, 2005. (32 refs.)
Background. Many cancer risk factors are correlated with one another, and the presence of I risk factor may be a marker for other unhealthy behaviors. In this article, we focus on smokeless tobacco (ST), a known risk factor for oral leukoplakia and oral cancer, and the cancer risk factors associated with its use. Methods. We analyzed cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) I and the 1982-1984 NHANES I Epidemiologic Follow-up Study. Risk factor information was available on individuals 25-74 years of age, most of whom would be middle age or elderly today. Results. Older subjects, Black males, and those living in the Southern Unite States had the highest prevalence of ST use. ST use was associated with current smoking (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5), former smoking (OR, 1.6; 95% Cl, 1.4-2.0), low fruit and vegetable intake, low SES, increased alcohol consumption (among nonsmoking ST users), and increased body mass index, all of which elevate cancer risk. Conclusion. Physicians and dentists should ask their patients about current or former ST use. Identification of ST users should prompt the physician or dentist to inquire about other chronic disease risk factors that the patient may have and to educate the ST using patient about ways to reduce their risk of cancer. Copyright 2005, American Association for Cancer Education.
A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: Effects on patient outcomes.
Campbell E; Walsh RA; Sanson-Fisher R; Burrows S; Stojanovski E. Tobacco Control 15(2): 97-102, 2006. (37 refs.)
Objective: To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics. Design: Group randomised trial. Setting: 22 antenatal clinics in New South Wales, Australia. Intervention: Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail-out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail-out plus feedback, training, and ongoing support with midwife facilitator. Main outcome measures: Independent cross sectional surveys of women on a second or subsequent visit undertaken pre-dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO). Subjects: 5849 women pre-dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post-dissemination (2302 SD, 2843 ID). Results: There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post-dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID). Conclusions: Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control. Copyright 2006, BMJ Publishing Group.
Treating tobacco use and dependence in clinical practice. (review).
Cornuz J. Expert Opinion on Pharmacotherapy 7(6): 783-792, 2006. (46 refs.)
Physicians are in a unique position to advise smokers to quit by the ability to integrate the various aspects of nicotine dependence. This review provides an overview of the intervention strategies for smokers presented in a primary care setting. The strategies that are used for smoking cessation counselling differ according to the patient's readiness to quit. For smokers who do not intend to give up smoking, physicians should inform about tobacco use and the benefits of cessation. For smokers who are dissonant, physicians should use motivational strategies, such as discussing the barriers to successful cessation and their solutions. For smokers who are ready to quit, the physician should show strong support, help set a date to quit, prescribe pharmaceutical therapies for nicotine dependence, such as nicotine replacement therapy (i.e., gum, transdermal patch, nasal spray, mouth inhaler, lozenges, and micro and sublingual tablets) and/or bupropion (an atypical antidepressant thought to work by blocking the neural re-uptake of dopamine and/or noradrenaline), with instructions for use, and suggest behavioural strategies to prevent relapse. The efficacy of all of these pharmacotherapies is comparable, roughly doubling the cessation rates over control conditions. Copyright 2006, Ashley Publications Ltd.
Improving general medical care for persons with mental and addictive disorders: Systematic review.
Druss BG; von Esenwein SA. General Hospital Psychiatry 28(2): 145-153, 2006. (94 refs.)
Objective: To conduct a systematic review of studies of interventions designed to improve general medical care in persons with mental and addictive disorders. Methods: Following Cochrane Collaboration guidelines, a comprehensive search through October 2005 was conducted in multiple bibliometric indexes using search terms related to primary medical care and mental health/addictive disorders. Two assessors independently extracted information on linkage, quality, outcomes and costs of care. Results: Six randomized trials met the preestablished search criteria. The interventions spanned a continuum of approaches for improving treatment, ranging from on-site medical consultation, through team-based approaches, to models involving facilitated referrals to primary care. The studies demonstrated a substantial positive impact on linkage to and quality of medical care; there was evidence of health improvement and improved abstinence rates in patients with greater medical comorbidity. The three studies that assessed expenditures found the programs to be cost-neutral from a health-plan perspective. Conclusion: A small but growing body of research suggests that a range of models may hold potential for improving these patients' health and health care, at a relatively modest cost. Future work should continue to develop and test approaches to this problem that can be tailored to local system needs and capacities. Copyright 2006, Elsevier Science Publishing Co.
Screening and brief intervention for alcohol problems in a university student health clinic.
Ehrlich PF; Haque A; Swisher-McClure S; Helmkamp J. Journal of American College Health 54(5): 279-287, 2006. (36 refs.)
The purposes of this study were (1) to determine whether a university student health center (SHC) is a feasible location to introduce a campus-based screening and brief intervention (SBI) program for alcohol and (2) to determine whether the patients seen in the SHC differ in terms of the prevalence and severity of alcohol-related problems compared with students reported by emergency department programs. The authors used motivational interview techniques to counsel subjects from a convenience sample of patients waiting for medical treatment in the SHC who had screened positive with the Alcohol Use Disorders Identification Test (AUDIT). The authors interviewed patients again after 3 months. Seventy-five percent of eligible students participated. Sixty percent screened positive and received an intervention. The authors contacted 66 students (51.2%) again after 3 months. Seventy-five percent of students interviewed again after 3 months reported that SBI was helpful, 92% found the information clear, and 90% thought that the SHC was a good place to learn this information. Copyright 2006, American College Health Association.
Therapy and supportive care of alcoholics: Guidelines for practitioners.
Kienast T; Heinz A. Digestive Diseases 23(3-4): 304-309, 2005. (42 refs.)
Background/Aims: Alcoholism is a widespread disorder in our societies. However, only a small percentage of alcoholics appear in specific psychotherapeutic treatment programs. The vast majority are seen by general practitioners or experts of other medical specialties where they are treated intensively for their alcohol-induced comorbidities. But the reason for these comorbidities, alcoholism itself, is rarely treated. This article provides a guideline for specialists and non-specialists on how to treat these patients correctly in nonspecific treatment programs and how to increase motivation to stay abstinent. Moreover, the concept can be quickly and easily integrated into the daily routine of any therapeutic team. Methods: Literature on the therapeutic methods of brief interventions, motivational interviewing as well as pharmacological relapse prevention was reviewed in PubMed for the years 1991 - 2005. Results/Conclusion: The burden of disease of alcoholism and alcohol abuse as primary disorders is highly evident but often underestimated even by therapists of various medical disciplines. Systematic studies of the brief intervention method, motivational interviewing and also pharmacological treatment with acamprosate have shown that these are potent methods that are easily used to increase the duration of abstinence and patients' motivation to take part in further specific treatment. Copyright 2006, Karger.
Helping 'them': Our role in recovery from opioid dependence. (editorial).
Loxterkamp D. Annals of Family Medicine 4(2): 168-171, 2006. (4 refs.)
The crisis of opioid addiction in America has been fueled by the diversion of prescription pain pills and the emergence of pure and inexpensive heroin. Until recently, benefits of and access to therapy were limited. This situation changed in 2003 with Food and Drug Administration approval of buprenorphine for the office-based treatment of opioid dependence. Now armed with a potent drug, primary care physicians can treat addicted patients in their own practice and from their own neighborhood, but first we must overcome deficiencies in our training and personal biases about addicts and what they need. This a report of one doctor's progress. Copyright 2006, Annals of Family Medicine Inc.
Randomized trial of onsite versus referral primary medical care for veterans in addictions treatment.
Saxon AJ; Malte CA; Sloan KL; Baer JS; Calsyn DA; Nichol P et al. Medical Care 44(4): 334-342, 2006. (26 refs.)
Background: Patients presenting for treatment of substance use disorders (SUDs) often exhibit medical comorbidities that affect functional health status and healthcare costs. Providing primary care within addictions clinics (onsite care) may improve medical and SUD treatment outcomes in this population. Objective: The objective of this study was to compare outcomes among Veterans' Administration (VA) patients who receive medical care within the SUD clinic and those referred to a general medicine clinic at the same facility. Methods: Veterans entering SUD treatment with a chronic medical condition and no current primary care were randomized to receive primary medical care: 1) onsite in the VA SUD clinic (n = 358), or 2) in the VA general internal medicine clinic (n = 362). Subjects were assessed at baseline and at 3, 6, and 12 months postrandomization. Intention-to-treat analyses used random-effects regression. Measures: Measures included SF-36 Physical and Mental Component Summaries (PCS, MCS), VA service utilization, SUD treatment retention, Addiction Severity Index (ASI) scores, 30-day abstinence, and total VA healthcare costs. Results: Over the study year, patients assigned to onsite care were more likely to attend primary care (adjusted odds ratio [OR] = 2.20; 95% confidence interval [CI] = 1.53-3.15) and to remain engaged in SUD treatment at 3 months (adjusted OR = 1.36; 1.00-1.84). Overall, outcomes on the MCS (but not the PCS) and the ASI improved significantly over time but did not differ by treatment condition. Total VA healthcare costs did not differ reliably across conditions. Conclusions: Compared with referral care, providing primary care within a VA addiction clinic increased primary care access and initial SUD treatment retention but showed no effect on overall health status or costs. Copyright 2006, J.B. Lippincott Co.
A practice-sponsored Web site to help patients pursue healthy behaviors: An ACORN study.
Woolf SH; Krist AH; Johnson RE; Wilson DB; Rothemich SF; Norman GJ et al. Annals of Family Medicine 4(2): 148-152, 2006. (41 refs.)
PURPOSE: We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change. METHODS In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction. RESULTS: During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians. CONCLUSIONS: Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance. Copyright 2006, Annals of Family Medicine Inc.
A customer service approach to implementing a best practice at community health centers.
Zahn D; Ruland J; Thomas S. Journal of Health Care for the Poor and Underserved 17(1, Supplement S): 53-58, 2006. (7 refs.)
It is important that strategies for implementing evidence-based best practices into clinical care are developed and tested. This is particularly true for community health centers (CHCs), which are a primary source of care for low-income patients. This article focuses on a customer service approach to implementing best practices in CHCs. The approach was designed to be responsive to the tremendous demands on and limited resources of CHC staff. The CHC staff were the customers of the project while the project team played a supportive role, acting as a full-service vendor to identify and meet staff needs. Although a tobacco system was the focus of this project, it is applicable to implementing in clinical settings generally, regardless of the particular health topic. Copyright 2006, Johns Hopkins University Press.
Role of the general practitioner in smoking cessation.
Zwar NA; Richmond RL. Drug and Alcohol Review 25(1): 21-26, 2006. (43 refs.)
This paper reflects on the role of general practitioners in smoking cessation and suggests initiatives to enhance general practice as a setting for effective smoking cessation services. This paper is one of a series of reflections on key issues in smoking cessation. In this article we highlight the extent that general practitioners (GPs) have contact with the population, evidence for effectiveness of GP advice, barriers to greater involvement and suggested future directions. General practice has an extensive population reach, with the majority of smokers seeing a GP at least once per year. Although there is level 1 evidence of the effectiveness of smoking cessation advice from general practitioners, there are substantial barriers to this advice being incorporated routinely into primary care consultations. Initiatives to overcome these barriers are education in smoking cessation for GPs and other key practice staff; teaching of medical students about tobacco and cessation techniques, clinical practice guidelines; support for guideline implementation; access to pharmacotherapies; and development of referral models. We believe the way forward for the role of the GPs is to develop the practice as a primary care service for providing smoking cessation advice. This will require education relevant to the needs of a range of health professionals, provision of and support for the implementation of clinical practice guidelines, access for patients to smoking cessation pharmacotherapies and integration with other cessation services such as quitlines. Copyright 2006, Taylor & Francis Ltd.
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