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...on Primary Care
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www.ProjectCork.org
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Spring 2007
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Opioid dependence: Rationale for and efficacy of existing and new treatments.
Fiellin DA; Friedland GH; Gourevitch MN. Clinical Infectious Diseases 43(Supplement 4): s173-s177, 2006. (54 refs.)
Opioid dependence is a chronic and relapsing medical disorder with a well-established neurobiological basis. Opioid agonist treatments, such as methadone and the recently approved buprenorphine, stabilize opioid receptors and the intracellular processes that lead to opioid withdrawal and craving. Both methadone and buprenorphine have been proven effective for the treatment of opioid dependence and can contribute to a decreased risk of human immunodeficiency virus (HIV) transmission. In addition, a buprenorphine/ naloxone combination appears to have a decreased potential for abuse or diversion, compared with that associated with methadone. Largely because of these properties, recent legislation now affords an unprecedented opportunity for general physicians to offer opioid agonist treatment through their offices. This review focuses on the neurobiological basis of opioid dependence, the rationale for methadone and buprenorphine treatments, and issues in prescribing these medications to patients with HIV infection. Copyright 2006, University of Chicago Press.
Family physicians and youth tobacco-free education: Outcomes of the Colorado Tar Wars Program.
Cain JJ; Dickinson P; Fernald D; Bublitz C; Dickinson LM; West D. Journal of the American Board of Family Medicine 19(6): 579-589, 2006. (25 refs.)
Background: Tar Wars is a national school-based tobacco-free education program operated by the American Academy of Family Physicians. The Tar Wars lesson uses an interactive 45-min session taught by volunteer family physicians in 4th- and 5th-grade classrooms and focuses on the short-term image-based consequences of tobacco use. In this study, we evaluated the effectiveness of the Tar Wars program in Colorado with both quantitative and qualitative measures. Methods: Students participating in the quantitative evaluation were tested before and after a Tar Wars teaching session using a 14-question test covering the short-term and image-based consequences of tobacco use, cost of smoking, tobacco advertising, and social norms of tobacco use. Qualitative evaluation of the program included guided telephone interviews and focus groups with participating students, teachers, and presenters. Results: Quantitative evaluation showed statistically significant improvement in correct responses for the 14 questions measured with an average increase in correct responses from 8.95 to 10.23. Three areas recommended by the Centers for Disease Control (CDC) for youth tobacco prevention showed greater change in correct responses, including cost of smoking, truth of tobacco advertising, and peer norms of tobacco use. Qualitative evaluation found that the overall message of the session was well received, that previously known tobacco information was reinforced by its presentation in a novel format, and that new information learned included cost of smoking, truth of tobacco advertising, and peer norms of tobacco use. Conclusions: The Tar Wars lesson plan is effective in increasing students' understanding about the short-term consequences of tobacco use, cost of tobacco use, truth of tobacco advertising, and peer norms. Tar Wars meets the CDC guidelines as one component of effective comprehensive youth tobacco prevention. Copyright 2006, American Board of Family Medicine.
Is some provider advice on smoking cessation better than no advice? An instrumental variable analysis of the 2001 National Health Interview Survey.
Bao YH; Duan NH; Fox SA. Health Services Research 41(6): 2114-2135, 2006. (32 refs.)
Research Objectives. To estimate the effect of provider advice in routine clinical contacts on patient smoking cessation outcome. Data Source. The Sample Adult File from the 2001 National Health Interview Survey. We focus on adult patients who were either current smokers or quit during the last 12 months and had some contact with the health care providers or facilities they most often went to for acute or preventive care. Study Design. We estimate a joint model of self-reported smoking cessation and ever receiving advice to quit during medical visits in the past 12 months. Because providers are more likely to advise heavier smokers and/or patients already diagnosed with smoking-related conditions, we use provider advice for diet/nutrition and for physical activity reported by the same patient as instrumental variables for smoking cessation advice to mitigate the selection bias. We conduct additional analyses to examine the robustness of our estimate against the various scenarios by which the exclusion restriction of the instrumental variables may fail. Principal Findings. Provider advice doubles the chances of success in (self-reported) smoking cessation by their patients. The probability of quitting by the end of the 12-month reference period increased from 6.9 to 14.7 percent, an effect that is of both statistical (p <.001) and clinical significance. Conclusions. Provider advice delivered in routine practice settings has a substantial effect on the success rate of smoking cessation among smoking patients. Providing advice consistently to all smoking patients, compared with routine care, is more effective than doubling the federal excise tax and, in the longer run, likely to outperform some of the other tobacco control policies such as banning smoking in private workplaces. Copyright 2006, Blackwell Publishing.
Training primary care clinicians in maintenance care for moderated alcohol use.
Friedmann PD; Rose J; Hayaki J; Ramsey S; Charuvastra A; Dube C et al. Journal of General Internal Medicine 21(12): 1269-1275, 2006. (45 refs.)
OBJECTIVES: To evaluate whether training primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior. DESIGN: We randomized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 1/4 hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have "made a change in their drinking and are trying to keep it that way"; and that they drank < 15 (men) or < 10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit. RESULTS: Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit. CONCLUSIONS: Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry. Copyright 2006, Blackwell Publishing.
Smoking during pregnancy: Where next for stage-based interventions?
Lawrence WT; Haslam C. Journal of Health Psychology 12(1): 159-169, 2007. (55 refs.)
Pregnancy is a 'window of opportunity' for encouraging positive behaviour change, such as quitting smoking. Associations have been shown between smoking stage of change and other health behaviour during pregnancy. For example, women in the precontemplative stage have poorer assessment of risks associated with smoking, feel less personally responsible for their unborn child's health and in turn are less likely to adopt health-promoting behaviour. Stage of change models are a popular tool within the health services, but the results of stage-based smoking cessation interventions are mixed. Identifying the crucial components of effective interventions is an important imperative for research in this area. This article reviews the literature to ascertain these components and makes recommendations for designing effective interventions. Copyright 2007, Sage.
Safety, efficacy, and feasibility of office-based prescribing and community pharmacy dispensing of methadone: Results of a pilot study in New Mexico.
Tuchman E; Gregory C; Simson M; Drucker E. Addictive Disorders and their Treatment 5(2): 43-51, 2006. (10 refs.)
OBJECTIVE: This article is the third in a series on office-based methadone treatment in primary care settings in conjunction with community pharmacies and social work. The study purpose is to examine the safety, efficacy, and feasibility of a physician office based, community pharmacy, and social work (OBP/CPD) model of care as compared to routine methadone maintenance treatment in a program (MMTP). METHODS: A 1 year pilot study was conducted from September 2003 to December 2004. Twenty-six stable female methadone maintenance patients were randomized to either methadone maintenance at a physician office, community pharmacy, and social work (n=14) or routine care at a MMTP (n=12). The main outcome measures are retention in methadone treatment and illicit drug use compared between the 2 groups in an equivalency design. RESULTS: Retention in methadone treatment during the 12-month period of pharmacy dispensing was 100%, as compared with one in the control group. Three of 13 (23%) patients in OBP/CPD had evidence of illicit opiate use during the study period, compared with 7 of 9 (78%) MMTP patients. Three of 13 (23%) OBP/CPD patients compared with 4 of 9 (44%) MMTP patients had urine toxicology positive for cocaine. One of 13 (8%) OBP/CPD patients compared with 4 of 9 (44%) MMTP patients had urine toxicology results positive for benzodiazepines. CONCLUSIONS: This study represents the first study of office-based methadone maintenance in conjunction with community pharmacy dispensing of methadone that has been directly compared with usual care in an MMTP. Findings support the safety, efficacy, and feasibility of office-based prescribing in conjunction with community pharmacy dispensing and social work treatment of methadone to expand options for methadone maintenance treatment for stable patients. Copyright 2006, Lippincott Williams & Wilkins.
Exploring differences in caseloads of rural and urban healthcare providers in Alaska and New Mexico.
Brems C; Johnson ME; Warner TD; Roberts LW. Public Health 121(1): 3-17, 2007. (46 refs.)
Objectives: Although it is commonly accepted that rural healthcare providers face demands that are both qualitatively and quantitatively different from those faced by urban providers, this conclusion is based largely on data from healthcare consumers and relies on qualitative work with small sample sizes, surveys with small sample sizes, theoretical reviews and anecdotal reports. To enhance our knowledge of the demands faced by rural healthcare providers and to gain the perspectives of healthcare providers themselves, this study explored the caseloads of rural providers compared with those of urban providers. Method: An extensive survey of over 1500 licensed clinicians across eight physical and behaviourat healthcare provider groups in Alaska and New Mexico was undertaken to explore differences in caseloads based on community size (small rural, rural, small urban, urban), state (Alaska, New Mexico) and discipline (health, behaviourat). Results: Findings indicated numerous caseload differences between community sizes that were consistent across both states, with complex case presentations being described most commonly by small rural and rural providers. Substance abuse, alcohol use, cultural diversity, economic disadvantage and age diversity were issues faced more often by providers in rural and small rural communities than by providers in small urban and urban communities. Rural, but not small rural, providers faced challenges around work with prisoners and individuals needing involuntary hospitalization. Although some state and discipline differences were noted, the most important findings were based on community size. Conclusions: The findings of this study have important implications for provider preparation and training, future research, tailored resource allocation, public health policy, and efforts to prevent 'burnout' of rural providers. Copyright 2007, WB Saunders Co.
Buprenorphine and HIV primary care: New opportunities for integrated treatment. Introduction. (editorial).
Khalsa J; Vocci F; Altice F; Fiellin D; Miller V. Clinical Infectious Diseases 43(Supplement 4): s169-s172, 2006. (15 refs.)
Drug abuse and infection with human immunodeficiency virus (HIV) are associated with high rates of morbidity and mortality, but, because of medical, social, and legal factors, opiate addiction/dependence is a major obstacle to successful treatment of disease-for example, treatment of acquired immunodeficiency syndrome (AIDS) with highly active antiretroviral therapy. In an effort to improve the opportunity for treatment of drug abuse and HIV infection, the Forum for Collaborative HIV Research, in collaboration with the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, the Centers for Disease Control and Prevention, and other agencies, presented a workshop entitled "Buprenorphine in the Primary HIV Care Setting." Participants reviewed and discussed current issues, such as the introduction of and sources for the provision of buprenorphine in HIV primary care settings and strategies for integrating treatment of HIV-infected drug abusers, all of which are covered in this supplement. Copyright 2006, University of Chicago Press.
Expressive writing for high-risk drug dependent patients in a primary care clinic: A pilot study.
Baikie K; Wilhelm K; Johnson B; Boskovic M; Wedgwood L; Finch A et al. Harm Reduction Journal 3(article 34), 2006. (36 refs.)
Background: Previous research has shown that expressive writing is beneficial in terms of both physical and emotional health outcomes. This study aimed to investigate the effectiveness and acceptability of a brief expressive writing intervention for high-risk drug dependent patients in a primary care clinic, and to determine the relationship between linguistic features of writing and health outcomes. Methods: Participants completed four 15-minute expressive writing tasks over a week, in which they described their thoughts and feelings about a recent stressful event. Self-report measures of physical (SF-12) and psychological health (DASS-21) were administered at baseline and at a two-week follow-up. Fifty-three participants were recruited and 14 (26%) completed all measures. Results: No statistically significant benefits in physical or psychological health were found, although all outcomes changed in the direction of improvement. The intervention was well-received and was rated as beneficial by participants. The use of more positive emotion words in writing was associated with improvements in depression and stress, and flexibility in first person pronoun use was associated with improvements in anxiety. Increasing use of cognitive process words was associated with worsening depressive mood. Conclusion: Although no significant benefits in physical and psychological health were found, improvements in psychological wellbeing were associated with certain writing styles and expressive writing was deemed acceptable by high-risk drug dependent patients. Given the difficulties in implementing psychosocial interventions in this population, further research using a larger sample is warranted. Copyright 2006, BioMed Central.
Spirometry and smoking cessation advice in general practice: A randomised clinical trial.
Buffels J; Degryse J; Decramer M; Heyrman J. Respiratory Medicine 100(11): 2012-2017, 2006. (30 refs.)
Rationale: To assess the success rate of smoking cessation with the "minimal intervention strategy" in general practice, and to determine the influence of spirometry on this success rate. Methods: Training in smoking cessation advice was given to 16 general practitioners (GPs). During 12 weeks, these GPs screened their practice population for smoking habits, the degree of dependence on nicotine, and the motivation to quit smoking. Patients willing to stop were randomised to a group that underwent a single office spirometry, or to a control group. The GPs were asked to support the attempts with the minimal intervention strategy. Success rates were compared after 6, 12 and 24 months. Results: On a population of 5590 patients, 1206 smokers were identified (22%). To the vulnerable group, identified following the Prochaska and Di Clemente scheme, the proposal was made to change smoking behaviour. Two hundred and twenty-one patients undertook an attempt of smoking cessation. Nicotine replacement therapy (NRT) or bupropion was prescribed in 51% of the attempts. Sixty-four sustained quitters were counted after 6 months (29%), 43 after 1 year (19%) and 33 after 2 years (15%). We found a small but statistically non-significant difference in success rate in favour of the group that underwent office spirometry. Conclusion: GPs can motivate almost 20% of their smoking population to quit smoking. The success rate with the minimal intervention strategy was 19% after 1 year and 15% after 2 years. We found no arguments in favour of confronting smokers with their lung function as a tool for enhancing smoking cessation. Copyright 2006, WB Saunders.
A national epidemiological study of co-morbid substance abuse and psychiatric illness in primary care between 1993-1998 using the General Practice Research Database.
Frisher M; Crome I; Croft P; Millson D; Collins J; Conolly A. Drugs: Education, Prevention, and Policy 12(Supplement 1): 82-84, 2005. (0 refs.)
Data from 1.4 million patients in 230 practices in England and Wales were used to determine the nature and extent of co-morbidity of substance abuse and another psychiatric disorders between 1993 and 1998. Among the findings were that there were at least 195,000 patients with these comorbid conditions and 3.5 million consultations involving comorbid patients. It was found also that 80-90% of patients consulted for both in any year were doing so for the first time, and about 50% of the cases continue to receive treatment for substance abuse or psychiatric illness. Efforts were made to determine whether these illnesses were recorded in general practice records. A validation study found that over 90% of patients treated for either condition were known to their general practitioner. The number of patients developing co-morbidity in primary care is increasing and there is a significant impact on health services. Comparing patients with co-morbidities to those with mono-morbid conditions, there was an estimated excess of 1,115,751 consultation in England and Wales from 1993-1998. Compared to age and sex matched controls, the number of excess consultations in 2,285,922 patients. It was found that those patients with co-morbidities who had secondary care psychiatric services had fewer A and E visits. Of concern is the higher rate of increase for co-morbidities among younger persons. There is also a higher rate among socioeconomically disadvantages persons. What is unknown is the extent to which substance abuse increases the rate of other co-morbidity. Policy implications are outlined. Copyright 2007, Project Cork.
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