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...on Primary Care
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www.ProjectCork.org
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Summer 2009
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The impact of education and school-based counseling on children's and adolescents' views of substance abuse
Anderson SW; Moore PA. Journal of Child & Adolescent Substance Abuse 18(1): 16-23, 2009. (7 refs.)
The purpose of this study was to investigate if a school-based education and counseling program (Life Skills Training Program) would have an impact on school-aged children/adolescents' views of substance abuse. The study also investigated the degree and direction of change. Participants were 338 elementary or middle-school students in the metro Houston, Texas, area. Results indicated that preexisting views significantly differed from post-intervention views, and that the Life Skills Training Program provided participants with a more accurate view of substance abuse. Findings support formulated hypotheses and effectiveness of the Life Skills Training Program with the sampled population. Copyright 2009, Haworth Press.
Early detection of addictive behaviour in primary health care. Use of MULTICAGE CAD-4
Monje MTR; Perez EJP; Giron MF; Alonso FG; Cuesta TS. Atencion Primaria 41(1): 25-32, 2009. (36 refs.)
Objective: To find out the frequency of specific disorders within the general population using primary healthcare relating to the control of impulses with addictive risk. Design: A cross-sectional descriptive study. Location: Urban health centre, Area 9 of the Madrid Health Service (Spain). Participants: A total of 457 patients who came to primary care (PA) were selected by consecutive sampling. Method: Self-completion of the MULTICAGE-CAD4 survey (which measure eight scales for the risky behaviour being studied). Results: There was a risk in at least one of the scales in 46.4% of the sample, of which 17.3% (13.7-20.9) showed risky behaviour on the alcohol scale; 9% (6.2-11.7) for other drugs; 4.4% (2.4-6.4) for gambling; 9.4% (6.6-12.2) for addiction to the Internet; 4.8% (2.7-6.7) for addiction to videogames; 18.8% (15.1-22.5) for eating disorders; 16% (12.5-19.4) for compulsive shopping and 5.5% (3.3-7.7) for addiction to sex. The occurrence of addiction to alcohol, gambling and sex were higher for men, while eating disorders were more prevalent in women. Conclusions: We are facing a widespread set of problems related to addictions that are often hidden; this study shows that these addictions can be detected within primary healthcare by effective screening tools such as MULTICAGE CAD-4, which is both economic, and easy to implement within primary healthcare centres. Copyright 2009, Ediciones Dyma S A.
Cost-effective primary care-based strategies to improve smoking cessation: More value for money
Salize HJ; Merkel S; Reinhard I; Twardella D; Mann K; Brenner H. Archives of Internal Medicine 169(3): 230-235, 2009. (26 refs.)
Background: Evidence from cost-effective smoking cessation programs is scarce. This study determined the cost-effectiveness of 3 smoking cessation strategies as provided by general practitioners (GPs) in Germany. Methods: In a cluster-randomized smoking cessation trial, rates and intervention costs for 577 smoking patients of 82 GPs were followed up for 12 months. Three smoking cessation treatments were tested: (1) GP training plus GP remuneration for each abstinent patient, (2) GP training plus cost-free nicotine replacement medication and/or bupropion hydrochloride for the patient, and (3) a combination of both strategies. Smoking abstinence at 12 months was the primary outcome used to calculate incremental cost-effectiveness ratios and net monetary benefits. Results: Intervention 1 was not effective compared with treatment as usual (TAU). Interventions 2 and 3 each proved to be cost-effective compared separately with TAU. When applying a 95% level of certainty of cost-effectiveness against TAU, (sic)9.80 or (sic)6.96, respectively, had to be paid for each additional 1% of patients abstinent at 12 months (maximum willingness to pay). That means that in intervention 2, (sic)92.12 per patient in the program must be invested to gain 1 additional quitter (as opposed to (sic)39.10 paid per patient during the trial). In intervention 2, the cost was (sic)82.82, as opposed to (sic)50.04. Neither of these 2 cost-effective treatments proved to be superior to the other. The cost-effectiveness of both treatments was stable against TAU in sensitivity analyses. (The exchange rate from October 1, 2003, was used; (sic)1 = $1.17.) Conclusions: Both treatments have a high potential to reduce smoking-related morbidity at a low cost. It is highly recommended that they be implemented as a routine service offered by GPs because in many countries, health insurance plans currently do not fund nicotine replacement therapy. Copyright 2009, American Medical Association.
Effectiveness of a stepped primary care smoking cessation intervention (ISTAPS study): Design of a cluster randomised trial
Cabezas C; Martin C; Granollers S; Morera C; Ballve JL; Zarza E et al. BMC Public Health 9: e-article 48, 2009. (33 refs.)
Background: There is a considerable body of evidence on the effectiveness of specific interventions in individuals who wish to quit smoking. However, there are no large-scale studies testing the whole range of interventions currently recommended for helping people to give up smoking; specifically those interventions that include motivational interviews for individuals who are not interested in quitting smoking in the immediate to short term. Furthermore, many of the published studies were undertaken in specialized units or by a small group of motivated primary care centres. The objective of the study is to evaluate the effectiveness of a stepped smoking cessation intervention based on a trans-theoretical model of change, applied to an extensive group of Primary Care Centres (PCC). Methods/Design: Cluster randomised clinical trial. Unit of randomization: basic unit of care consisting of a family physician and a nurse, both of whom care for the same population (aprox. 2000 people). Intention to treat analysis. Study population: Smokers (n = 3024) aged 14 to 75 years consulting for any reason to PCC and who provided written informed consent to participate in the trial. Intervention: 6-month implementation of recommendations of a Clinical Practice Guideline which includes brief motivational interviews for smokers at the precontemplation - contemplation stage, brief intervention for smokers in preparation-action who do not want help, intensive intervention with pharmacotherapy for smokers in preparation-action who want help, and reinforcing intervention in the maintenance stage. Control group: usual care. Outcome measures: Self-reported abstinence confirmed by exhaled air carbon monoxide concentration of <= 10 parts per million. Points of assessment: end of intervention period and 1 and 2 years post-intervention; continuous abstinence rate for 1 year; change in smoking cessation stage; health status measured by SF-36. Discussion: The application of a stepped intervention based on the stages of a change model is possible under real and diverse clinical practice conditions, and improves the smoking cessation success rate in smokers, besides of their intention or not to give up smoking at baseline. Copyright 2009, BioMed Central Ltd.
GPs' office based methadone maintenance treatment in Trieste, Italy. Therapeutic efficacy and predictors of clinical response
Michelazzi A; Vecchiet F; Leprini R; Popovic D; Deltito J; Maremmani I. Heroin Addiction and Related Clinical Problems 10(2): 27-38, 2008. (50 refs.)
Objective: To evaluate the effectiveness of methadone treatment carried out by General Practitioners (GPs) and to identify response treatment factors. Methods: 33 subjects with heroin addiction according to the DSM-IV-R criteria, 25 males and 9 females with an average age of 26 6 years, were placed in an observational protocol with average duration of 429 273 days. Retention rate, substance use, overall clinical improvement, social adaptation, quality of life and psychopathologic symptoms were used as outcome measures. In order to assess predictors of treatment response dropout and non-dropout subjects were compared at baseline. Results: At the end of the observational period, 6 patients (18.2%) had a positive outcome, 8 (24.2%) negative outcome, while 19 (57.6%) were still in treatment with a Cumulative retention of 60% at the end of the third year of observation. In 25 non-dropout patients baseline-endpoint improvement results were statistically significant for substance use, global clinical evaluation, psychological, social and occupational functioning, and craving. They also showed improvement in all of investigated psychopathological and quality of life dimensions. There were no significant side effects associated with their treatment. Patients with higher severity of illness, with problematic relationships with spouse/partner, difficulty with socialization and organization of leisure, with an altered mental state at beginning of treatment, subjects with dual diagnosis (especially bipolar disorder), with greater severity of obsessive-compulsive symptoms, interpersonal sensitivity, depression, violence, with greater severity of psychopathological symptoms. with the largest number of problematic areas as regarding the quality of life, patients with a low close of methadone given for treatment were considered most at risk for abandoning treatment. Conclusions: Methadone treatment carried out by General Practitioners appears safe and effective, especially in less severe patients treated with adequate doses, without severe psychopathology, without dual diagnoses (particularly bipolar disorder) and with quality of life impairment only in limited areas. Copyright 2008, Pacini Editore.
Identifying and screening for psychological and comorbid medical and psychological disorders in medical settings. (editorial)
Kessler R. Journal of Clinical Psychology 65(3, Special Issue): 253-267, 2009. (47 refs.)
There is increased attention to the medical and economic consequences of psychological problems comorbid with medical issues. There is also a clear awareness that most psychological problems are assessed and responded to in nonpsychiatric medical settings. This has furthered interest and attention in implementing screening procedures to better identify psychological, behavioral, and substance abuse problems in medical settings. Such interest is taking the form of recommendations from federal government task forces, and the funding of large projects to include screening in medical settings. At the same time there has been further attention to brief, valid, and reliable measures with which to capture psychological comorbidities. However, there have been multiple concerns raised about a variety of issues concerning the utility and effectiveness of such screening procedures and the identification of multiple issues to be considered in screening design. The author outlines and reviews the rationale and concerns about screening, identifies the issues that need to be considered in screening program development, and describes the efforts to develop a screening capacity in a rural family practice. Copyright 2009, John Wiley & Sons.
Initiation of health behavior discussions during primary care outpatient visits
Flocke SA; Kelly R; Highland J. Patient Education and Counseling 75(2): 214-219, 2009. (43 refs.)
Objective: Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits. Methods: Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed. Results: Physicians initiated 65% of discussions and used two overarching strategies (I) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change. Conclusions: Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice. Practice Implications: Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance Copyright 2009, Elsevier Science.
Mailed treatment to augment primary care for alcohol disorders: A randomised controlled trial
Kavanagh D; Connolly JM. Drug and Alcohol Review 28(1): 73-80, 2009. (26 refs.)
Introduction and Aims. Remote delivery of interventions is needed to address large numbers of people with alcohol use disorders who are spread over large areas. Previous correspondence trials typically examined its effects as stand-alone treatment. This study aimed to test whether adding postal treatment to general practitioner (GP) support would lower alcohol use more than GP intervention alone. Design and Methods. A single-blind, randomised controlled trial with a crossover design was conducted over 12 months on 204 people with alcohol use disorders. Participants in an immediate correspondence condition received treatment over the first 3 months; those receiving delayed treatment received it in months 3-6. Results. Few participants were referred from GPs, and little intervention was offered by them. At 3 months, 78% of participants remained in the study. Those in immediate treatment showed greater reductions in alcohol per week, drinking days, anxiety, depression and distress than those in the delayed condition. However, post-treatment and follow-up outcomes still showed elevated alcohol use, depression, anxiety and distress. Greater baseline anxiety predicted better alcohol outcomes, although more mental distress at baseline predicted dropout. Discussion and Conclusions. The study gave consistent results with those from previous research on correspondence treatments, and showed that high levels of participant engagement over 3 months can be obtained. Substantial reductions in alcohol use are seen, with indications that they are well maintained. However, many participants continue to show high-risk alcohol use and psychological distress. Copyright 2009, Taylor & Francis.
Oral cancer knowledge, attitudes and practices: A survey of dentists and primary care physicians in Massachusetts
Applebaum E; Ruhlen TN; Kronenberg FR; Hayes C; Peters ES. Journal of the American Dental Association 140(4): 461-467, 2009. (28 refs.)
Background. The authors conducted a study to assess dentists' and primary care physicians' oral cancer knowledge, attitudes and practices in the Commonwealth of Massachusetts. Methods. The authors mailed a 38-item, pretested questionnaire to a stratified sample of dentists and primary care physicians in Massachusetts. The sample population included all general medicine, internal medicine and family practice physicians listed with the Massachusetts Board of Registration in Medicine and all Massachusetts Dental Society members. The authors invited a random sample of more than 1,000 clinicians to participate in the survey. They assessed knowledge, attitudes and practices of respondents and performed a bivariate analysis of responses to questions by using statistical software. Results. Forty-nine percent of physicians reported performing an oral cancer examination in patients aged 40 to 55 years, compared with 92 percent of dentists (P < .001). For patients 56 years or older, 54 percent of physicians reported performing oral cancer examinations, compared with; 93 percent of dentists (P < .001). More than 96 percent of physicians reported that they asked patients about smoking and alcohol use. However, only 9 percent of physicians and 39 percent of dentists were able to identify the two most common sites on which oral cancer develops (P < .001). Fifty-seven percent of dentists and 24 percent of physicians correctly identified the most common symptom of early oral cancer. Conclusion. This survey underscores the need to enhance oral cancer education among both professional groups. Copyright 2009, American Dental Association.
The association of alcohol dependence with general practice attendance
Proudfoot H; Teesson M. Drug and Alcohol Review 28(2): 154-159, 2009. (41 refs.)
Introduction and Aims. This study was designed to examine the relationship between alcohol dependence and general practitioner (GP) service attendance in Australia. Design and Methods. Data were analysed from the 1997 Australian National Survey of Mental Health and Wellbeing. In this survey, a representative sample of the Australian population was interviewed to ascertain past 12 month psychiatric diagnoses for all major mental disorders as well as the use of primary and other health services (n = 10 641, 79% response rate). Results. People with alcohol dependence comorbid with other psychiatric disorders have higher rates of service usage than those without such disorders. Discussion and Conclusions. Alcohol dependence comorbid with mental disorders has a significant impact on GP service in Australia. High rates of service use by individuals with such comorbidities were a considerable burden for GP services. Copyright 2009, Taylor & Francis.
Trends in drug misuse recorded in primary care in the UK from 1998 to 2005
Frisher M; Martino O; Crome I; Croft P. Journal of Public Health 31(1): 69-73, 2009. (18 refs.)
A recent report by the UK Drugs Policy Commission has highlighted the high levels of drug use in Britain and this has been interpreted as indicative of ineffective drug polices. However, the interpretation was based on sporadic self-report data and indirect extrapolation. This paper assesses trends in the prevalence and incidence of drug misuse in the UK from 1998 to 2005 as recorded in general practice. The study was a retrospective analysis of the General Practice Research Database. The study cohort comprised similar to 900 000 patients each year from 183 general practices. Among the Government's key target age group (16-24 years), there was a marked decrease in both prevalence and incidence of illicit drug misuse from 1998 to 2002 (P < 0.01). In older adults (25-59 years), the pattern was more variable during the first part of this period, but incidence remained stable from 2002 to 2005. These data indicate that the problematic drug use in the UK may be declining and that the policies may be more effective than has been previously thought. General practice data are nonetheless only part of the picture in terms of understanding the prevalence of problematic drug use. Copyright 2009, Oxford University Press.
Who conceals their smoking status from their health care provider?
Stuber J; Galea S. sNicotine & Tobacco Research 11(3): 303-307, 2009. (12 refs.)
The decline in the social acceptability of tobacco use has the potential consequence that smokers may conceal their smoking from health care providers. To assess the frequency and correlates of concealing one's smoking status from a health care provider, we analyzed data from the New York Social Environment Study, a cross-sectional random-digit-dialed telephone survey of 4,000 adult New York City residents surveyed between June and December 2005 (cooperation rate = 54%). A total of 835 current smokers were asked if they had ever kept their smoking status a secret from a doctor or another health care provider. Multiple items assessed the social unacceptability of smoking. Other potential correlates of smoking status nondisclosure were demographics, health status, frequency of tobacco use, and dependence. Some 8% of respondents (N = 63) reported ever keeping their smoking status a secret from a health provider. Nondisclosure of smoking status was more common among respondents who perceived high compared with low levels of smoker-related stigma (perceptions that they were devalued because they smoke; odds ratio [OR] = 2.83, 95% CI = 1.14-7.01) and among respondents who reported that smoking was not allowed in their home (OR = 2.04, 95% CI = 1.01-4.11) in a multiple logistic regression analysis that adjusted for demographics, health status, frequency of tobacco use, and dependence. No other factors were associated with nondisclosure in this model. A small percentage of smokers may conceal their smoking status from their health care providers, and those who do are more likely to perceive their tobacco use to be socially unacceptable. Copyright 2009, Oxford University Press.
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