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...on Primary Care
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www.ProjectCork.org
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Winter 2009
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Parental alcohol screening in pediatric practices.
Wilson CR; Harris SK; Sherritt L; Lawrence N; Glotzer D; Shaw JS et al. Pediatrics 122(5): E1022-E1029, 2008. (38 refs.)
OBJECTIVES. Pediatricians are in an ideal position to screen parents of their patients for alcohol use. The objective of this study was to assess parents' preferences regarding screening and intervention for parental alcohol use during pediatric office visits for their children. METHODS. A descriptive multicenter study that used 3 pediatric primary care clinic sites (rural, urban, suburban) was conducted between June 2004 and December 2006. Participants were a convenience sample of consecutively recruited parents who brought children for medical care. Parents completed an anonymous questionnaire that contained demographics; 2 alcohol-screening tests (TWEAK and Alcohol Use Disorders Identification Test); and items that assessed preferences for who should perform alcohol-screening, acceptance of screening, and preferred interventions if the screening result was positive. RESULTS. A total of 929 of 1028 eligible parents agreed to participate, and 879 of 929 completed surveys that yielded sufficient data for analysis. Most participants were mothers. A total of 101 of 879 parents screened positive on either the TWEAK or the Alcohol Use Disorders Identification Test. Parents with a negative alcohol screen (alcohol-negative) were more likely than parents with a positive alcohol screen (alcohol-positive) to report that they would agree to being asked about their alcohol use. There were no significant differences in preferences within alcohol-positive and alcohol-negative groups for screening by the pediatrician or computer-based questionnaire. Most preferred interventions for the alcohol-positive group were for the pediatrician to initiate additional discussion about drinking and its effect on their child, give educational materials about alcoholism, and refer for evaluation and treatment. Alcohol-positive men were more accepting than alcohol-positive women of having no intervention. CONCLUSIONS. A majority of parents would agree to being screened for alcohol problems in the pediatric office. Regardless of their alcohol screen status, parents are accepting of being screened by the pediatrician, a computer-based questionnaire, or a paper-and-pencil survey. Parents who screen positive prefer that the pediatrician discuss the problem further with them and present options for referral. Copyright 2008, American Academy of Pediatrics.
In-practice management versus quitline referral for enhancing smoking cessation in general practice: A cluster randomized trial.
Borland R; Balmford J; Bishop N; Segan C; Piterman L; McKay-Brown L et al. Family Practice 25(5): 382-389, 2008. (24 refs.)
Background and objective. GPs are an important source of smoking cessation advice. This research examined whether a model encouraging GP referral of patients who smoke to a specialist service would be acceptable and effective for increased smoking cessation when compared with a model of in-practice management. Methods. The study design was cluster randomized controlled trial. Practices were randomized to one of two interventions, at a rate of 1:2: (i) standard in-practice GP management or (ii) referral to a quitline service. The main outcome measures were sustained abstinence of >= 1 month duration at 3-month follow-up and >= 10 months duration at 12 months, using intention to treat analysis. Results. At 3-month follow-up, patients in the referral condition were twice as likely to report sustained abstinence than those in the in-practice condition [12.3% compared with 6.9%; odds ratio (OR) = 1.92 (95% confidence interval (CI) 1.17-3.13]. At 12-month follow-up, patients in the referral condition had nearly three times the odds of sustained abstinence [6.5% compared with 2.6%; OR = 2.86 (95% CI 0.94-8.71)]. The intervention effect was mediated by the amount of help received outside the practice. Conclusions. This research provided evidence that GPs referring smokers to an evidence-based quitline service results in increased cessation. The benefit is largely due to patients in the referral condition receiving more external help than patients in the in-practice condition, as they received equivalent practice-based help. Where suitable services exist, we recommend that referral become the normative strategy for management of smoking cessation in general practice to complement any practice-based help provided. Copyright 2008, Oxford University Press.
Screening for alcohol misuse in elderly primary care patients: A systematic literature review. (review)
Berks J; McCormick R. International Psychogeriatrics 20(6): 1090-1103, 2008. (45 refs.)
Background: Alcohol problems in the elderly are common and frequently undetected, and therefore a potential target for a screening program. Method: Using Medline, Psychinfo and reference lists from relevant publications, articles were identified testing pen-and-paper screens in the primary care population aged over 60 years. Results: Using standard definitions of alcohol problems, conventional screens adapted for use in the elderly have performances similar to screens in the younger primary care population. However, it can be argued that special screens perform better for the elderly. Conclusions: The Alcohol Use Disorders Identification Test is a useful screen for detecting harmful and hazardous drinking in the elderly while the CAGE is valuable when screening for dependence. In the future, the Alcohol-Related Problems Survey, a computer-based screen, may prove to be superior if practical implementation problems can be overcome. Copyright 2008, Cambridge University Press.
Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: Data from the 2005 National Alcohol Survey.
Cherpitel CJ; Ye Y. Drug and Alcohol Dependence 97(3): 226-230, 2008. (16 refs.)
?Background: Substance use problems are overrepresented in probability samples of patients in primary care settings including the emergency room (ER) compared to the general population. While large proportions of those with alcohol or drug use disorders are most likely to obtain services for these problems outside the mental health or substance abuse treatment system, accounting, in part, for this overrepresentation, little is known about the association of alcohol misuse or drug use with health services utilization in the general population. Methods: The prevalence and predictive value of alcohol misuse and drub use on ER and primary care use was analyzed on 6919 respondents from the 2005 National Alcohol Survey (NAS). Results: Among those reporting an ER visit during the last year, 24% were positive for risky drinking (14+ drinks weekly for then and 7+ for females and/or 5+/4+ in a day in the last 12 months), 8% for problem drinking. 3% for alcohol dependence, and 7% for illicit drug use greater than monthly. Figures for primary care users were, respectively: 24%, 5%, 3%, and 3%. ER users were more likely to be positive for problem drinking and greater than monthly illicit drug use compared to non-ER users, while no significant differences were found in substance use for users and non-users of primary care. In logistic regression controlling for gender, age, and health insurance, problem drinkers were twice as likely as non-problem drinkers (Odds ratio, OR = 1.99) (p < 0.01), and those reporting greater than monthly drug use were almost twice as likely as those using drugs less frequently or not at all (OR = 1.92; p = 0.01) to report ER use, while those reporting alcohol dependence were 1.63 times more likely to report primary Care use (p < 0.05). Conclusion: These data support the belief that both the ER and other primary care settings are important sites for identifying those with substance use problems and for initiating a brief intervention. Copyright 2008, Elsevier Science.
HIV-positive patients' discussion of alcohol use with their HIV primary care providers.
Metsch LR; Pereyra M; Colfax G; Dawson-Rose C; Cardenas G; McKirnan D et al. Drug and Alcohol Dependence 95(1/2): 37-44, 2008. (59 refs.)
Objectives: We investigated the prevalence of HIV-positive patients discussing alcohol use with their HIV primary care providers and factors associated with these discussions. Methods: We recruited 1225 adult participants from 10 HIV care clinics in three large US cities from May 2004 to 2005. Multivariate logistic regression analysis was used to assess the associations between self-reported rates of discussion of alcohol use with HIV primary care providers in the past 12 months and the CAGE screening measure of problem drinking and sociodemographic variables. Results: Thirty-five percent of participants reported discussion of alcohol use with their primary care providers. The odds of reporting discussion of alcohol were three times greater for problem drinkers than for non-drinkers, but only 52% of problem drinkers reported such a discussion in the prior 12 months. Sociodemographic factors associated with discussion of alcohol use (after controlling for problem drinking) were being younger than 40, male, being non-white Hispanic (compared with being Hispanic), being in poorer health, and having a better patient-provider relationship. Conclusions: Efforts are needed to increase the focus on alcohol use in the HIV primary care setting, especially with problem drinkers. Interventions addressing provider training or brief interventions that address alcohol use by HIV-positive patients in the HIV primary care setting should be considered as possible approaches to address this issue. Copyright 2008, Elsevier Science.
The implementation of buprenorphine/naloxone in college health practice.
DeMaria PA; Patkar AA. Journal of American College Health 56(4): 391-393, 2008. (19 refs.)
Opiate abuse and dependence have become important concerns for college healthcare providers. The passage of the Drug Addiction Treatment Act of 2000 and the approval of the combination buprenorphine/naloxone for office-based treatment of opiate dependence have increased the options available for college students and their helath care providers. The authors review the pharmacology of buprenorphine/naloxone and discuss how it can be implemented in college health practice. They also present a case report. Copyright 2008, Heldref Publications.
Integrating screening and interventions for unhealthy behaviors into primary care practices.
Aspy CB; Mold JW; Thompson DM; Blondell RD; Landers PS; Reilly KE et al. American Journal of Preventive Medicine 53(5, Supplement S): S373-S380, 2008. (65 refs.)
Background: Four unhealthy behaviors (tobacco use, unhealthy diet, physical inactivity, and risky alcohol use) contribute to almost 37% of deaths in the U.S. However, routine screening and interventions targeting these behaviors are not consistently provided in primary care practices. Methods: This was an implementation study conducted between October 2005 and May 2007 involving nine practices in three geographic clusters. Each cluster of practices received a multicomponent intervention sequentially addressing the four behaviors in three G-month cycles (unhealthy diet and physical inactivity were combined). The intervention included baseline and monthly audits with feedback; five training modules (addressing each behavior plus stages of change [motivational interviewing]); practice facilitation; and bimonthly quality-circle meetings. Nurses, medical assistants, or both were taught to do screening and very brief interventions such as referrals and handouts. The clinicians were taught to do brief interventions. Outcomes included practice-level rates of adoption, implementation, and maintenance. Results: Adoption: Of 30 clinicians invited, nine agreed to participate (30%). Implementation: Average screening and brief-intervention rates increased 25 and 10.8 percentage points, respectively, for all behaviors. However, the addition of more than two behaviors was generally unsuccessful. Maintenance: Screening increases were maintained across three of the behaviors for up to 12 months. For both unhealthy diet and risky alcohol use, screening rates continued to increase throughout the study period, even during the periods when the practices focused on the other behaviors. The rate of combined interventions returned to baseline for all behaviors 6 and 12 months after the intervention period. Conclusions: it appears that the translational strategy resulted in increased screening and interventions. There were limits to the number of interventions that could be added within the time limits of the project. Inflexible electronic medical records, staff turnover, and clinicians' unwillingness to allow greater nurse or medical-assistant involvement in care were common challenges. Copyright 2008, Elsevier Science.
Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: Data from the 2005 National Alcohol Survey.
Cherpitel CJ; Ye Y. Drug and Alcohol Dependence 97(3): 226-230, 2008. (16 refs.)
Background: Substance use problems are overrepresented in probability samples of patients in primary care settings including the emergency room (ER) compared to the general population. While large proportions of those with alcohol or drug use disorders are most likely to obtain services for these problems outside the mental health or substance abuse treatment system, accounting, in part, for this overrepresentation, little is known about the association of alcohol misuse or drug use with health services utilization in the general population. Methods: The prevalence and predictive value of alcohol misuse and drub use on ER and primary care use was analyzed on 6919 respondents from the 2005 National Alcohol Survey (NAS). Results: Among those reporting an ER visit during the last year, 24% were positive for risky drinking (14+ drinks weekly for then and 7+ for females and/or 5+/4+ in a day in the last 12 months), 8% for problem drinking. 3% for alcohol dependence, and 7% for illicit drug use greater than monthly. Figures for primary care users were, respectively: 24%, 5%, 3%, and 3%. ER users were more likely to be positive for problem drinking and greater than monthly illicit drug use compared to non-ER users, while no significant differences were found in substance use for users and non-users of primary care. In logistic regression controlling for gender, age, and health insurance, problem drinkers were twice as likely as non-problem drinkers (Odds ratio, OR = 1.99) (p < 0.01), and those reporting greater than monthly drug use were almost twice as likely as those using drugs less frequently or not at all (OR = 1.92; p = 0.01) to report ER use, while those reporting alcohol dependence were 1.63 times more likely to report primary Care use (p < 0.05). Conclusion: These data support the belief that both the ER and other primary care settings are important sites for identifying those with substance use problems and for initiating a brief intervention. Copyright 2008, Elsevier Science.
Trends in alcohol- and drug-related ED and primary care visits: Data from three US national surveys (1995-2005).
Cherpitel CJ; Ye Y. American Journal of Drug and Alcohol Abuse 34(5): 576-583, 2008. (17 refs.)
Objective: To evaluate trends in alcohol- and drug-related emergency department (ED) and primary care visits over the previous decade. Method: A trend analysis was conducted on substance-related health services visit data, based on self-reported drinking or drug use within six hours prior to an injury or illness event, from the 1995, 2000, and 2005 National Alcohol Surveys. Results: Although an upward trend was observed in alcohol-related ED visits from 1995 to 2005, this increase was not significant. A significant trend was found for drug-related ED visits from .6% in 1995 to 3.7% in 2005 (p < .01). In multiple logistic regression, year of survey (2000 vs. 1995) was positively predictive of drug-related ED visits, controlling for gender, age, ethnicity, and health insurance coverage; however, year of survey (2005 vs. 2000) was not significant. Conclusion: These data suggest that drug-related ED visits are continuing to increase, although the increase has not been as substantial between 2000 and 2005 as that which was observed between 1995 and 2000 and highlight the opportunity provided by the ED and primary care settings for screening and brief intervention for substance-related problems. These findings also suggest that Healthy People 2010 objectives calling for a reduction in substance-related visits may not be reached. Copyright 2008, Marcel Dekker Inc.
The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: A randomized trial.
Copello A; Templeton L; Orford J; Velleman R; Patel A; Moore L et al. Addiction 104(1): 49-58, 2009. (31 refs.)
Objectives: A randomized trial to compare two levels of an intervention (full versus brief) for use by primary health-care professionals with family members affected by the problematic drug or alcohol use of a close relative. Design: A prospective cluster randomized comparative trial of the two interventions. Setting: A total of 136 primary care practices in two study areas within the West Midlands and the South West regions of England. Participants: A total of 143 family members affected by the alcohol or drug problem of a relative were recruited into the study by primary health-care professionals. All recruited family members were seen on at least one occasion by the professional delivering the intervention and 129 (90 %) were followed-up at 12 weeks. Main outcome measures: Two validated and standardized self-completion questionnaires measuring physical and psychological symptoms of stress (Symptom Rating Test) and behavioural coping (Coping Questionnaire) experienced by the family members. It was predicted that the full intervention would show increased reduction in both symptoms and coping when compared to the brief intervention. Results: The primary analysis adjusted for clustering, baseline symptoms and stratifying variables (location and professional group) showed that there were no significant differences between the two trial arms. The symptom score at follow-up was 0.23 [95% confidence interval (CI): _3.65, +4.06] higher in the full intervention arm than in the brief intervention arm, and the coping score at follow-up was 0.12 (95% CI: _5.12, +5.36) higher in the full intervention arm than in the brief intervention arm. Conclusions: A well-constructed self-help manual delivered by a primary care professional may be as effective for family members as several face-to-face sessions with the professional. Copyright 2009, Society for the Study of Addiction.
Common measures, better outcomes (COMBO): A field test of brief health behavior measures in primary care.
Fernald DH; Froshaug DB; Dickinson LM; Balasubramanian BA; Dodoo MS; Holtrop JS et al. American Journal of Preventive Medicine 53(5, Supplement S): S414-S422, 2008. (47 refs.)
Background: Primary care offices have been characterized as underutilized settings for routinely addressing health behaviors that contribute to premature death and unnecessary suffering. Practical tools are needed to routinely assess multiple health risk behaviors among diverse primary care patients. The performance of a brief set of behavioral measures used in primary care practice is reported here. Methods: Between August 2005 and January 2007, 75 primary care practices assessed four health behaviors, using a 21-item patient self-report questionnaire for adults or a 16-item questionnaire for adolescents. Data were collected via telephone, paper, or electronic means, either with or without assistance. The performance of these measures was evaluated by describing risk-behavior prevalences, combinations of risk behaviors, and missing data. Results: Of 227 adolescents and 5358 adults, most patients completed all of the survey questions. Two or more unhealthy behaviors were reported by 47.1% of adolescents and 69.2% of adults. Percentages of adults who completed all the survey items varied by health behavior: tobacco use, 98.5%; diet, 98.2%; physical activity, 96.2%; alcohol use, 85.1%. Missing data rates were higher for unassisted patient self-reporting. Conclusions: A relatively brief set of health behavior measures was usable in a variety of primary care settings with adults and adolescents. The performance of these measures was uneven across behaviors and administration modes, but yielded estimates of unhealthy behaviors consistent overall with what would be expected based on published population estimates. Further work is needed on measures for alcohol use and physical activity to bring practical assessment tools for key health behaviors to routine primary care practice. Copyright 2008, Elsevier Science.
Keeping morality out and the GP in consultations in Danish general practice as a context for smoking cessation advice.
Guassora AD; Tulinius AC. Patient Education and Counseling 73(1): 28-35, 2008?
Objective: To describe consultations in Danish general practice as a context for a mass strategy of smoking cessation advice. Methods: The focus of the study was on consultations for health problems that were not related to smoking. Interviews with eleven patients and their six GPs were grounded in observation of their own consultations. Results: Patients and GPs agreed that the GP should adopt all attitude of moral acceptance towards patients. Ideals of moral acceptance of patients in general practice Consultations were challenged by the prevailing negative moral values associated with smoking. A general aim of mutuality in the conversation in consultations could not always be achieved in smoking cessation advice. Achieving mutuality was especially a problem when smoking cessation advice was repeated at short intervals. Conclusion: Two elements of Danish general practice consultations were challenged by smoking cessation advice to patients without smoking-related illness: the ideal of moral acceptance of patients in general practice consultations held by GPs and patients and the wish for mutuality in the conversation during consultations. Practice implications: A conversation about smoking based on motivational interviewing would fit in the context of Danish general practice. Relieving the conversation of blocks due to moral implications, however, is still a challenge. Copyright 2008, Elsevier Science.
HIV-positive patients' discussion of alcohol use with their HIV primary care providers.
Metsch LR; Pereyra M; Colfax G; Dawson-Rose C; Cardenas G; McKirnan D et al. Drug and Alcohol Dependence 95(1/2): 37-44, 2008. (59 refs.)
Objectives: We investigated the prevalence of HIV-positive patients discussing alcohol use with their HIV primary care providers and factors associated with these discussions. Methods: We recruited 1225 adult participants from 10 HIV care clinics in three large US cities from May 2004 to 2005. Multivariate logistic regression analysis was used to assess the associations between self-reported rates of discussion of alcohol use with HIV primary care providers in the past 12 months and the CAGE screening measure of problem drinking and socio-demographic variables. Results: Thirty-five percent of participants reported discussion of alcohol use with their primary care providers. The odds of reporting discussion of alcohol were three times greater for problem drinkers than for non-drinkers, but only 52% of problem drinkers reported such a discussion in the prior 12 months. Sociodemographic factors associated with discussion of alcohol use (after controlling for problem drinking) were being younger than 40, male, being non-white Hispanic (compared with being Hispanic), being in poorer health, and having a better patient-provider relationship. Conclusions: Efforts are needed to increase the focus on alcohol use in the HIV primary care setting, especially with problem drinkers. Interventions addressing provider training or brief interventions that address alcohol use by HIV-positive patients in the HIV primary care setting should be considered as possible approaches to address this issue. Copyright 2008, Elsevier Science.
The Development of Materials on Ecstasy and Related Drugs for Health Care Practitioners. NDARC Technical Report No. 287.
Silins E; Copeland J; Dillon P; McGregor I; Caldicott D. Sydney: National Drug and Alcohol Research Centre, 2007.
The amphetamine derivative 3,4-methylenedioxymethamphetamine (MDMA) or commonly called ecstasy is a widely used illicit drug. In addition polydrug use is the norm among ecstasy and related drug users and that includes a range of pharmaceuticals (e.g. benzodiazepines, sidenafil) and supplements (e.g. 5-hydroxytryptophan (5-HTP), St. John's wort) are deliberately combined with ecstasy, often for contradictory purposes. This practice is of concern as the popularity of ecstasy is continuing to increase in Australia and a number of ecstasy-pharmaceutical combinations can have serious health consequences. One of the emerging harms associated with ecstasy use is serotonin toxicity, commonly referred to as serotonin syndrome. The present study grew from these concerns, and aimed to: Identify gaps in knowledge among GPs about the effects and harms of use and the management of young people who are prescribed pharmaceutical drugs; Identify gaps in knowledge among frontline (e.g. Emergency Department) healthcare professionals about the effects and harms of this drug use; Identify the patterns of use related to the practice of combining ecstasy with pharmaceutical drugs, in particular antidepressants, and to explore the experiences of users when visiting a GP; Inform the development of resource materials for healthcare practitioners. The anticipated materials are described. There are 38 tables. Copyright 2008, Project Cork.
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