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...on Primary Care
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www.ProjectCork.org
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Summer 2012
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Challenges to alcohol and other drug discussions in the general practice consultation.
Moriarty HJ; Stubbe MH; Chen L; Tester RM; Macdonald LM; Dowell AC et al. Family Practice 29(2): 213-222, 2012. (38 refs.)
Background. There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. Aim. To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. Design. Analysis of video-recorded primary care consultations. Setting. New Zealand General Practice. Methods. Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. Results. AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. Conclusions. Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed. Copyright 2012, Oxford University Press.
Delivery of preventive care: The National Canadian Family Physician Cancer and Chronic Disease Prevention Survey.
Katz A; Lambert-Lanning A; Miller A; Kaminsky B; Enns J. Canadian Family Physician 58(1): E62, 2012. (43 refs.)
Objective: To determine family physicians' practice of, knowledge about, and attitudes toward delivering preventive care during periodic health examinations (PHEs). Design A stratified sample of 5013 members of the College of Family Physicians of Canada were randomly selected to receive a questionnaire by mail. Descriptive analysis was performed on a national data set of 1010 respondents. Setting: Canada. Participants A sample of family physicians from each Canadian province. Main outcome measures Physicians were asked questions about whether they addressed aspects of preventive care, such as tobacco smoking, nutrition, physical activity, alcohol intake, and sun exposure with patients during PHEs. The questions were designed to gauge attitudes and identify barriers to the provision of preventive care. Results: Most respondents (87% to 89%) indicated that they were comfortable counseling their patients about issues such as nutrition, physical activity, and alcohol consumption; however, many of these respondents did not refer their patients to specialists or provide them with additional resources to educate patients about the health risks of their conditions. While tobacco smoking risks and cessation were addressed by most family physicians (79%) during PHEs, other topics, such as sun exposure, were often overlooked. Conclusion The results of this survey indicate that while many family physicians follow the evidence-based guidelines for preventive care, current levels of preventive care in the primary care setting are below national standards. It is critical that Canadians receive optimal preventive care to improve the outlook of the chronic disease burden on the health care system. Copyright 2012, College of Family Physicians Canada.
Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes. (review).
Niccols A; Milligan K; Sword W; Thabane L; Henderson J; Smith A. Harm Reduction Journal 9: e-article 14, 2012. (50 refs.)
Background: Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes. Objectives: As part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes. Methods: Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes. Results: There were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, ds = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health. Conclusions: This is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues. Copyright 2012, BioMed Central.
New recreational drugs and the primary care approach to patients who use them. (review).
Winstock AR; Mitcheson L. British Medical Journal 344: e-article e288, 2012. (34 refs.)
New drugs of misuse, including ketamine, G-hydroxybutyrate (GHB), and a range of synthetic stimulants, have become part of global recreational drug culture. Use in combination with other substances (especially alcohol) is common and increases the associated health risks. These drugs are associated with non-specific risks of intoxication and substance specific toxicological harms. Assessment and feedback using a motivational approach and provision of information about harm reduction are useful interventions that can be delivered in primary care. Referral to specialist services might be needed to manage complex withdrawal or specific harms. This clinical review addresses common examples of these new drugs, and provide a framework for conducting an interview in the primary care setting with people who may have problems with their use. Since evidence relating to these substances is inevitably limited, thus it draws upon case series, observational studies, consensus guidelines, our own clinical experiences, and those of our colleagues. Copyright 2012, BMJ Publishing.
Prescribing practices and the prescription drug epidemic: Physician intervention strategies.
Smith DE. Journal of Psychoactive Drugs 44(1): 68-71, 2012. (21 refs.)
Prescription drug abuse is increasingly recognized as the United States' fastest growing drug problem, rising dramatically since the early 2000s, and particularly affecting adolescents and young adults. Federal officials are urging legislation to educate physicians about the use and effects of potent narcotics, which are increasingly being prescribed for chronic pain. ASAM developed strategies in the 1980s to identify the small minority of misprescribers and focused educational and retraining efforts on these individuals. As health reform and more prevalent pain management put more primary care physicians in a gatekeeper role to manage the medical care of addicts, these clinicians must become aware of the abuse potential of the powerful narcotics they prescribe. Increased reference to state-maintained controlled medication databases can also reduce misprescribing. Copyright 2012, Haight-Ashbury Publications.
Prescription opioid use and misuse: Piloting an educational strategy for rural primary care physicians.
Srivastava A; Kahan M; Jiwa A. Canadian Family Physician58(4): E210-E216, 2012. (31 refs.)
Objective: To evaluate the feasibility and effectiveness of a multifaceted educational intervention to improve the opioid prescribing practices of rural family physicians in a remote First Nations community. Design: Prospective cohort study. Setting: Sioux Lookout, Ont. Participants: Family physicians. Interventions: Eighteen family physicians participated in a 1-year study of a series of educational interventions on safe opioid prescribing. Interventions included a main workshop with a lecture and interactive case discussions, an online chat room, video case conferencing, and consultant support. Main outcome measures: Responses to questionnaires at baseline and after 1 year on knowledge, attitudes, and practices related to opioid prescribing. Results: The main workshop was feasible and was well received by primary care physicians in remote communities. At 1 year, physicians were less concerned about getting patients addicted to opioids and more comfortable with opioid dosing. Conclusion: Multifaceted education and consultant support might play an important role in improving family physician comfort with opioid prescribing, and could improve the treatment of chronic pain while minimizing the risk of addiction. Copyright 2012, College of Family Physicians of Canada.
SBIRT: A key to integrate prevention and treatment of substance abuse in primary care.
McCance-Katz EF; Satterfield J. American Journal on Addictions 21(2): 176-177, 2012. (10 refs.)
The 2009 National Survey on Drug Use and Health reported that 21.8 million, or 8%, of those over age 12 had used illicit substances in the past month, 23.7% (59.6 million) reported binge drinking, and 6.8% (17.1 million) reported regular heavy drinking. This makes substance abuse one of the most common medical disorders in the United States. Furthermore, at best only 10% of those in need of treatment, actual receiving treatment. A single screening question is recommended for primary care, community health settings, and emergency departments. The question is "in the past year, have you had any times when you had 5 (for women, 4) or more drinks at one sitting?" The authors discusses efforts by SAMHSA has launched a 17 site, medical residency training program to promote the core SBIRT clinical skills among physicians, with the goal of bringing one of the most common medical disorders into the medical mainstream. Copyright 2012, American Academy of Addiction Psychiatry.
Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction.
Kraus ML; Alford DP; Kotz MM; Levounis P; Mandell TW et al. Journal of Addiction Medicine 5(4): 254-263, 2011. (93 refs.)
Objectives: Opioid addiction affects over 2 million patients in the United States. The advent of buprenorphine and the passage of the Drug Addiction Treatment Act in 2000 have revolutionized the opioid treatment delivery system by granting physicians the ability to administer office-based opioid treatment (OBOT), thereby giving patients greater access to treatment. The purpose of this consensus panel was to synthesize the most current evidence on the use of buprenorphine in the office-based setting and to make recommendations that will enable and allow additional physicians to begin to treat opioid-addicted individuals. Methods: Literature published from 2000 to 2009 was searched using the PubMed search engine and yielded over 375 articles published in peer-reviewed journals, including some that were published guidelines. These articles were submitted to a consensus panel composed of researchers, educators, and clinicians who are leaders in the field of addiction medicine with specific expertise in the use of OBOT. The panel discussed results and agreed upon consensus recommendations for several facets of OBOT. Results: On the basis of the literature review and consensus discussions, the panel developed a series of findings, conclusions, and recommendations regarding the use of buprenorphine in office-based treatment of opioid addiction. Conclusions: Therapeutic outcomes for patients who self-select office-based treatment with buprenorphine are essentially comparable to those seen in patients treated with methadone programs. There are few absolute contraindications to the use of buprenorphine, although the experience and skill levels of treating physicians can vary considerably, as can access to the resources needed to treat comorbid medical or psychiatric conditions-all of which affect outcomes. It is important to conduct a targeted assessment of every patient to confirm that the provider has resources available to meet the patient's needs. Patients should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated, referred, or both for help in meeting all their care needs, including medical care, psychiatric care, and social assistance. Current literature demonstrates promising efficacy of buprenorphine, though further research will continue to demonstrate its effectiveness for special populations, such as adolescents, pregnant women, and other vulnerable populations. Since the time of this review, several new studies have provided new data to continue to improve our understanding of the safety and efficacy of buprenorphine for special patient populations. Copyright 2011, Lippincott, Williams & Wilkins.
The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature. (review).
Islam MM; Topp L; Day CA; Dawson A; Conigrave KM. International Journal of Drug Policy 23(2): 94-102, 2012. (64 refs.)
Background: Injecting drug users (IDUs) are at increased risk of health problems ranging from injecting-related injuries to blood borne viral infections. Access to primary healthcare (PHC) is often limited for this marginalised group. Many seek care at emergency departments and some require hospital admission due to late presentation. The costs to both the individual and the health system are such that policymakers in some settings have implemented IDU-targeted PHC centres, with a number of models employed. However, there is insufficient evidence on the effectiveness of these centres to inform health service planning. A systematic review examining such interventions is not possible due to the heterogeneous nature of study designs. Nevertheless, an integrative literature review of IOU-targeted PHC may provide useful insights into the range of operational models and strategies to enhance the accessibility and acceptability of these services to the target population. Methods: Available literature describing the impact of IDU-targeted PHC on health outcomes, cost implications and operational challenges is reviewed. A narrative synthesis was undertaken of material sourced from relevant journal publications, grey literature and policy documents. Results: Several models have proven accessible and acceptable forms of PHC to IDUs, improving the overall healthcare utilisation and health status of this population with consequent savings to the health system due to a reduction in visits to emergency departments and tertiary hospitals. Conclusions: Although such findings are promising, there remains a dearth of rigorous evaluations of these targeted PHC, with the public health impact of such outlets yet to be systematically documented. Copyright 2012, Elsevier Science.
The Pap smear screening as an occasion for smoking cessation and physical activity counselling: Baseline characteristics of women involved in the SPRINT randomized controlled trial.
Chellini E; Gorini G; Carreras G; Giordano L; Anghinoni E; Iossa A et al. BMC Public Health 11: article 906, 2011. (29 refs.)
Background: Gender-specific smoking cessation strategies have rarely been developed. Evidence of effectiveness of physical activity (PA) promotion and intervention in adjunct to smoking cessation programs is not strong. SPRINT study is a randomized controlled trial (RCT) designed to evaluate a counselling intervention on smoking cessation and PA delivered to women attending the Italian National Health System Cervical Cancer Screening Program. This paper presents study design and baseline characteristics of the study population. Methods/ Design: Among women undergoing the Pap examination in three study centres (Florence, Turin, Mantua), participants were randomized to the smoking cessation counselling [S], the smoking cessation + PA counselling [S + PA], or the control [C] groups. The program under evaluation is a standard brief counselling on smoking cessation combined with a brief counselling on increasing PA, and was delivered in 2010. A questionnaire, administered before, after 6 months and 1 year from the intervention, was used to track behavioural changes in tobacco use and PA, and to record cessation rates in participants. Discussion: Out of the 5,657 women undergoing the Pap examination, 1,100 participants (55% of smokers) were randomized in 1 of the 3 study groups (363 in the S, 366 in the S + PA and 371 in the C groups). The three arms did not differ on any demographic, PA, or tobacco-use characteristics. Recruited smokers were older, less educated than non-participant women, more motivated to quit (33% vs. 9% in the Preparation stage, p < 0.001), smoked more cigarettes per day (12 vs. 9, p < 0.001), and were more likely to have already done 1 or more quit attempts (64% vs. 50%, p < 0.001). The approach of SPRINT study appeared suitable to enrol less educated women who usually smoke more and have more difficulties to quit. Copyright 2011, BioMed Central.
Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol.
Hingson RW; Heeren T; Edwards EM; Saitz R. Journal of General Internal Medicine 27(2): 179, 2012. (35 refs.)
Excessive alcohol consumption is most widespread among young adults. Practice guidelines recommend screening and physician advice, which could help address this common cause of injury and premature death. To assess the proportion of persons ages 18-39 who, in the past year, saw a physician and were asked about their drinking and advised what drinking levels pose health risk, and whether this differed by age or whether respondents exceeded low-risk drinking guidelines [daily (> 4 drinks for men/> 3 for women) or weekly (> 14 for men/> 7 for women)]. Survey of young adults selected from a national internet panel established using random digit dial telephone techniques. Adults age 18-39 who ever drank alcohol, n = 3,409 from the internet panel and n = 612 non-panel telephone respondents. Respondents were asked whether they saw a doctor in the past year; those who did see a doctor were asked whether a doctor asked about their drinking, advised about safe drinking levels, or counseled to reduce drinking. Of respondents, 67% saw a physician in the past year, but only 14% of those exceeding guidelines were asked and advised about risky drinking patterns. Persons 18-25 were the most likely to exceed guidelines (68% vs. 56%, p < 0.001) but were least often asked about drinking (34% vs. 54%, p < 0.001). Despite practice guidelines, few young adults are asked and advised by physicians about excessive alcohol consumption. Physicians should routinely ask all adults about their drinking and offer advice about levels that pose health risk, particularly to young adults. Copyright 2012, Springer.
Efficacy of a physicians' pocket guide about prenatal substance use: A randomized trial.
Midmer D; Kahan M; Kim T; Ordean A; Graves L. Substance Abuse 32(4): 175-179, 2011. (13 refs.)
A pocket guide on management of substance use during pregnancy was developed by a group of Canadian care providers. One hundred and fifteen family medicine residents in 6 Canadian teaching sites were randomized to receive either the pocket guide or a paper summary on similar clinical topics, based on UpToDate, a comprehensive Web-based resource. At baseline, both groups completed a survey containing questions on beliefs, attitudes, experience, and training on pregnancy and substance use. Participants then answered 28 multiple choice questions about substance use in pregnancy, using either the pocket guide or UpToDate. Finally participants were asked to rate ease of use for the 2 resources. The results showed that the pocket guide group had higher knowledge scores than the UpToDate group overall and at each study site (61.27% vs. 42.86%, P < .001). The residents found the pocket guide easier to use than UpToDate (mean = 2.73 vs. 4.36, P < .001), and were more likely to want to use it again (96% for pocket card, 78% for UpToDate, P = .005). It is concluded that the pocket guide is a practical source of clinical information at point of care, particularly for "orphan" subjects such as substance use in pregnancy. Copyright 2011, Taylor & Francis
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