Library Watch - On Primary Care

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...on Primary Care

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Spring 2011

Being questioned and receiving advice about alcohol and smoking in health care: Associations with patients' characteristics, health behavior, and reported stage of change

Ahacic K; Allebeck P; Thakker KD. Substance Abuse Treatment, Prevention and Policy 5: e-article 30, 2010. (43 refs.)
Background: Alcohol habits are more rarely addressed than other health behavior topics in Swedish health care. This study examined whether differences between topics could be explained by their different associations with patient characteristics or by the differences in the prevalence of the disadvantageous health behavior, i.e., excessive alcohol use and smoking. The study moreover examined whether simply being asked questions about behavior, i.e., alcohol use or smoking, was associated with reported change. Methods: The study was based on a cross-sectional postal survey (n = 4 238, response rate 56.5 percent) representative of the adult population in Stockholm County in 2003. Retrospective self-reports were used to assess health care visits during the past 12 months, the questions and advice received there, patients characteristics, health behavior, and the present stage of change. Logistic regression analysis was used to estimate the associations among the 68 percent who had visited health care. Results: Among the health care visitors, 23 percent reported being asked about their alcohol habits, and 3 percent reported receiving advice or/and support to modify their alcohol use -fewer than for smoking, physical exercise, or diet. When regression models adjusted for patient characteristics, the differences between health behaviors in the extent of questioning and advice remained. However, when the models also adjusted for smoking and alcohol consumption there was no difference between smoking and alcohol-related advice. In fact one-third of the present smokers and two-fifths of the persons dependent on alcohol reported having receiving advice the previous 12 months. Those who reported being asked questions or receiving advice more often reported a decreased alcohol use and similarly intended to cease smoking within 6 months. Questions about alcohol use were moreover related to a later stage of stage of change independently of advice among women but not among men. Conclusions: While most patients are never addressed, many in the target groups seem to be reached anyway. Besides advice, already addressing alcohol habits appears to be associated with change. The results also indicate that gender possibly plays a role in the relationship between advice and the stage of change.

Treatment practices and perceived challenges for European physicians treating opioid dependence

Bacha J; Reast S; Pearlstone A. Heroin Addiction and Related Clinical Problems 12(3): 9-19, 2010. (44 refs.)
This survey investigated the current practices and challenges of physicians treating opioid dependence in Germany, France, Italy and the UK. Doses favoured in Europe appeared to conflict with recommended best practice, with low mean methadone and buprenorphine maintenance doses reported (44.3 and 9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer than recommended at 14.4 days. Respondents also rated diversion and misuse management as their most difficult challenge in treating opioid dependence. These data suggest that prescribing practices are likely to increase this problem, as well as impeding treatment success by decreasing compliance and retention.

Update in addiction medicine for the generalist

Gordon AJ; Kunins HV; Rastegar DA; Tetrault JM; Walley AY. Journal of General Internal Medicine 26(1): 77-82, 2011. (56 refs.)
Generalist clinicians routinely care for patients who misuse or are dependent on alcohol, nicotine, and other drugs of abuse. These problems contribute to significant morbidity, health care utilization, cost, and preventable death.The aim of this update is to identify and examine recent advances in addiction medicine that have practice implications for generalist physicians and their patients. To accomplish this, we independently selected articles in the field of addiction medicine, summarized and critically appraised, and examined the articles in the context of their implications for generalist practice using methodology we used in prior updates. During an initial review, we identified articles through an electronic MedLine search (limited to human studies and in English) using search terms for alcohol, nicotine, and other drugs of abuse from January 2008 through January 2010. From the citations, the authors selected articles for more intensive review. All authors then agreed collectively on the important articles regarding addiction medicine that have implications for practice for generalist clinicians. Topics covered in this review include prescription drug abuse, overdose deaths related to prescription drug diversion, factors influencing risk of overdose of prescribed oioids, screening in primary care, impact of intervention on health status, pharamcotherapy for smoking cessation, office-based opioid agonist therapy.

Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain

Liebschutz JM; Saitz R; Weiss RD; Averbuch T; Schwartz S; Meltzer EC et al. Journal of Pain 11(11): 1047-1055, 2010. (59 refs.)
This study examined characteristics associated with prescription drug use disorder (PDUD) in primary care patients with chronic pain from a cross sectional survey conducted at an urban academically affiliated safety net hospital Participants were 18 to 60 years old had pain for >= 3 months took prescription or nonprescription analgesics and spoke English Measurements included the Composite International Diagnostic Interview (PDUD other substance use disorders (SUD) Posttraumatic Stress Disorder [PTSD]) Graded Chronic Pain Scale smoking status family history of SUD and time spent in jail Of 597 patients (41% male 61% black mean age 46 years) 110 (18 4%) had PDUD of whom 99 (90%) had another SUD. In adjusted analyses those with PDUD were more likely than those without any current or past SUD to report jail time (OR 5 1 95% Cl 2 8-9 3) family history of SUD (OR 3 4 1 9 6) greater pain related limitations (OR 3 8 1 2 11 7) cigarette smoking (OR 3 6 2-6 2) or to be white (OR 3 2 1 7-6) male (OR 1 9 1 1-3 5) or have PTSD (OR 1 9 1 1-3 4) PDUD appears increased among those with easily identifiable characteristics. The challenge is to determine who among those with risk factors can avoid with proper management developing the increasingly common diagnosis of PDUD. Perspective: This article examines risk factors for prescription drug use disorder (PDUD) among a sample of primary care patients with chronic pain at an urban academic safety net hospital. The findings may help clinicians identify those most at risk for developing PDUD when developing appropriate treatment.

Exploring primary care providers' interest in using patient navigators to assist in the delivery of tobacco cessation treatment to low income, ethnic/racial minority patients

Lubetkin EI; Lu WH; Krebs P; Yeung H; Ostroff JS. Journal of Community Health 35(6): 618-624, 2010. (52 refs.)
We examined attitudes and practices regarding tobacco cessation interventions of primary care physicians serving low income, minority patients living in urban areas with a high smoking prevalence. We also explored barriers and facilitators to physicians providing smoking cessation counseling to determine the need for and interest in deploying a tobacco-focused patient navigator at community-based primary care practice sites. A self-administered survey was mailed to providers serving Medicaid populations in New York City's Upper Manhattan and areas of the Bronx. Provider counseling practices were measured by assessing routine delivery (a parts per thousand yen80% of the time) of a brief tobacco cessation intervention (i.e., "5 A's"). Provider attitudes were assessed by a decisional balance scale comprising 10 positive (Pros) and 10 negative (Cons) perceptions of tobacco cessation counseling. Of 254 eligible providers, 105 responded (41%). Providers estimated 22% of their patients currently use tobacco and nearly half speak Spanish. A majority of providers routinely asked about tobacco use (92%) and advised users to quit (82%), whereas fewer assisted in developing a quit plan (32%) or arranged follow-up (21%). Compared to providers reporting < 80% adherence to the "5 A's", providers reporting a parts per thousand of 80% adherence tended to have similar mean Pros and Cons scores for Ask, Advise, and Assess but higher Pros and lower Cons for Assist and Arrange. Sixty four percent of providers were interested in providing tobacco-related patient navigation services at their practices. Although most providers believe they can help patients quit smoking, they also recognize the potential benefit of having a patient navigator connect their patients with evidence-based cessation services in their community.

Identifying prescription opioid use disorder in primary care: Diagnostic characteristics of the Current Opioid Misuse Measure (COMM)

Meltzer EC; Rybin D; Saitz R; Samet JH; Schwartz SL; Butler SF et al. Pain 152(2): 397-402, 2011. (31 refs.)
The Current Opioid Misuse Measure (COMM), a self-report assessment of past-month aberrant medication-related behaviors, has been validated in specialty pain management patients. The performance characteristics of the COMM were evaluated in primary care (PC) patients with chronic pain. It was hypothesized that the COMM could identify patients with prescription drug use disorder (PDD). English-speaking adults awaiting PC visits at an urban, safety-net hospital, who had chronic pain and had received any opioid analgesic prescription in the past year, were administered the COMM. The Composite International Diagnostic Interview served as the "gold standard," using DSM-IV criteria for PDD and other substance use disorders (SUDs). A receiver operating characteristic (ROC) curve demonstrated the COMM's diagnostic test characteristics. Of the 238 participants, 27 (11%) met DSM-IV PDD criteria, whereas 17 (7%) had other SUDs, and 194 (82%) had no disorder. The mean COMM score was higher in those with PDD than among all others (ie, those with other SUDs or no disorder, mean 20.4 [ SD 10.8] vs 8.4 [SD 7.5], P < .0001). A COMM score of >= 13 had a sensitivity of 77% and a specificity of 77% for identifying patients with PDD. The area under the ROC curve was 0.84. For chronic pain patients prescribed opioids, the development of PDD is an undesirable complication. Among PC patients with chronic pain-prescribed prescription opioids, the COMM is a promising tool for identifying those with PDD.

Older adults' inpatient and emergency department Uuilization for ambulatory-care-sensitive conditions: Relationship With Alcohol Consumption

Merrick ESL; Hodgkin D; Garnick DW; Horgan CM; Panas L; Ryan M et al. Journal of Aging and Health 23(1): 86-111, 2011. (60 refs.)
Objective: This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries. Method: This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission. Results: Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures. Discussion: Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Integrating addiction medicine into graduate medical education in primary care: The time has come

O'Connor PG; Nyquist JG; McLellan AT. Annals of Internal Medicine 154(1): 56-U192, 2011. (25 refs.)
Substance use disorders create an enormous burden of medical, behavioral, and social problems and pose a major and costly public health challenge. Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care. At the center of this failure is insufficient training for physicians about substance use disorders. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed the following 5 recommendations focused on improving training in substance abuse in primary care residency programs in internal medicine and family medicine: 1) integrating substance abuse competencies into training, 2) assigning substance abuse teaching the same priority as teaching about other chronic diseases, 3) enhancing faculty development, 4) creating addiction medicine divisions or programs in academic medical centers, and 5) making substance abuse screening and management routine care in new models of primary care practice. This enhanced primary care residency training should represent a major step forward in improving patient care.

Alcohol and sleep problems in primary care patients: A report from the AAFP National Research Network

Vinson DC; Manning BK; Galliber JM; Dickinson LM; Pace WD; Turner BJ. Annals of Family Medicine 8(6): 484-492, 2010. (46 refs.)
PURPOSE Hazardous and harmful drinking and sleep problems are common but their associations among patients seen in primary care have not been examined We hypothesized that greater levels of alcohol consumption would be associated with several self reported sleep problems. METHODS: In a cross sectional survey in primary care practices 94 participating clinicians recruited up to 30 consecutive adult patients and both clinicians and patients completed anonymous postvisit questionnaires. Patients were asked questions on demographics alcohol consumption cardinal symptoms of alcohol use disorders sleep quality, insomnia sleep apnea and symptoms of restless leg syndrome Multivariate analyses explored the associations of drinking status (none moderate or hazardous) and sleep problems adjusting for demographics and clustering of patients within physician. RESULTS Of 1 984 patients who responded 1 699 (85 6%) provided complete data for analysis. Respondents mean age was 50 4 years (SD 174 years) 67% were women, and 72 9% were white. Of these 22 3% reported hazardous drinking, 47 8% reported fair or poor overall sleep quality, and 7 3% reported a diagnos's or treatment of sleep apnea. Multivariate analyses showed no associations between drinking status and any measure of insomnia overall sleep quality, or restless legs syndrome symptoms Moderate drinking was associated with lower adjusted odds of sleep apnea compared with nondrinkers (OR = 0 61 95% CI 0 38 1 00) Using alcohol for sleep was strongly associated with hazardous drink ing (OR = 4 58 95% CI 2 97 708 compared with moderate drinking). CONCLUSIONS: Moderate and hazardous drinking were associated with few sleep problems. Using alcohol for sleep, however, was strongly associated with hazardous drinking relative to moderate drinking and may serve as a prompt for physicians to ask about excessive alcohol use

Inside the physician's black bag: Critical ingredients of brief alcohol interventions

Grossberg P; Halperin A; Mackenzie S; Gisslow M; Brown D; Fleming M. Substance Abuse 31(4): 240-250, 2010. (30 refs.)
Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians' collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.