[Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review]. / Stigmatisering van patiënten met een verslaving en de gevolgen voor de hulpverlening: een systematisch literatuuronderzoek.

BACKGROUND: Healthcare professionals are crucial in the identification and accessibility to treatment for people with substance use disorders. AIM: Objective of this literature review is to assess health professionals' attitudes towards patients with substance use disorders and to examine the consequences of these attitudes on healthcare delivery for these patients. METHOD: PubMed, Psycinfo and Embase were systematically searched for articles published between 2000-2011. Reviews, commentaries and letters were excluded, as were studies originating from non-Western countries. The search process yielded 1562 citations. After selection and quality assessment 28 studies were included. RESULTS: Health professionals generally have negative attitudes towards patients with substance use disorders. They perceive violence, manipulation, and poor motivation as impeding factors in the healthcare delivery for these patients. Health professionals also lack adequate education, training and support structures in working with this patient group. Negative attitudes of health professionals diminish patients' feelings of empowerment and subsequently treatment outcomes. Health professionals have a more task-oriented approach (e.g. less personal engagement and diminished empathy) in the delivery of healthcare for these patients. CONCLUSION: This review indicates that negative attitudes of health professionals towards patients with substance use disorders are common and contribute to suboptimal health care for these patients. However, few studies have evaluated the consequences of health professionals' negative attitudes towards patients with substance use disorders.

Dutch and Norwegian support of alcohol policy measures to prevent young people from problematic drinking: a cross-national comparison.

AIMS: To examine whether Dutch and Norwegian adults differ in their opinion on policy measures that may prevent young people from problematic drinking. METHODS: Data were derived from a web-based cross-sectional study. In this study, only Dutch and Norwegian adults (aged ≥24 years) were included (n(NL) = 5023, n(NO) = 1916). Opinions on policy items concerning restrictive and educational measures were examined together with alcohol consumption. RESULTS: Differences between the opinions of the Dutch and Norwegians concerning the restrictive and educational measures were small. In both countries, the support for restrictive measures was predicted by female gender, higher age and less own alcohol consumption. For the educational measures, the explained variance in the Norwegian and Dutch sample was relatively low; this indicates that opinion was more strongly predicted by other factors. CONCLUSION: This study indicates that, despite the differences between the Dutch and Norwegian alcohol policy, differences in opinion are small between Dutch and Norwegian respondents, especially regarding restrictive measures that may prevent young people from drinking.

Model fidelity of assertive community treatment for clients with first-episode psychosis: a target group-specific application.

Assertive community treatment (ACT) is described as a team treatment model designed to provide assertive, outreaching, comprehensive, community-based, rehabilitation-oriented and supportive psychiatric services for people with severe mental illness as reported by Drake et al. (Psychiatr Serv 52: 179-182, 2001) and Teague et al. (Psychiatr Serv 68: 216-232, 1998). This study explores variations in the way the original components of ACT are implemented for the target group of clients with a first-episode psychosis, and establishes whether these variations lead the treatment model to a higher, more valuable, outcome level. The study also describes how to achieve this optimally effective application of target group-specific treatment services.

Alcohol consumption in The Netherlands in the last decade: sharp decreases in binge drinking, especially among youngsters.

AIM: The aim of this study was to examine the development of alcohol consumption and 'binge drinking' in The Netherlands over the period 1997-2005. METHODS: Data from three national population surveys commissioned by the Dutch Ministry of Health were compared. RESULTS: Decreases in binge drinking have appeared, especially for youngsters, which are not explained by changes in the composition of the population according to religious orientation, and for which no other explanation can be given at present. CONCLUSION: Trends in binge drinking in The Netherlands can vary over relatively short spaces of time.

Alcohol intake and cardiovascular disease and mortality: the role of pre-existing disease.

OBJECTIVES: Pre-existing conditions have been postulated as possible causes of the J-shaped relationship between alcohol intake and cardiovascular disease. Two research questions have been addressed in this paper. First, whether never drinkers and former drinkers differ from moderate drinkers in terms of health, and if so, which health problems contribute to this difference. Second, whether the U-shaped relationship between current alcohol intake and cardiovascular disease or all-cause mortality could in part be explained by difference in pre-existing disease burden. DESIGN, SETTING AND PARTICIPANTS: A prospective case-cohort, the Lifestyle and Health Study, consisting of 16,210 men and women aged between 45 and 70 years. Alcohol intake and risk factors were assessed at baseline with a self-administered questionnaire. Medical information was obtained from general practitioners. Cardiovascular events and mortality were followed for a period of 5 years (1996-2001). MAIN RESULTS: Never drinkers and former drinkers were less healthy than moderate drinkers. They rated their health more often as poor, and often had more diseases, such as cardiovascular disease, diabetes, and also alcohol-related diseases. The difference in disease burden did not change the observed relationship between alcohol intake and cardiovascular events, and only partially changed the U-shaped relationship between alcohol intake and all-cause mortality. CONCLUSIONS: The found difference in health between never drinkers and former drinkers compared with moderate drinkers appeared to be only a partial explanation of the observed relationships between alcohol intake and cardiovascular disease, and between alcohol intake and all-cause mortality.

Communalization of health care: how to do it properly. Criteria for a just communalization of health care applied to the Dutch situation.

Communalization of health care refers to the increasing responsibility of citizens to look after their ill or handicapped fellow members of society and to provide care to them. Governments in Western Europe more and more develop health care policies directed at communalization of health care. The article discusses the care responsibilities of individuals based on the views of the philosophers Buber, Levinas, and Ricoeur and on the views of the family therapist Nagy. The care responsibilities of states are discussed in terms of the views of the political philosophers Rawls and Daniels and these are linked to right liberal, left liberal, and Christian-democrat views on care responsibilities of states. Thereupon, four criteria for a proper communalization of health care are proposed and different forms of health care policies with respect to communalization of care are assessed. In the last section, we look closely at several measures in the just reformed Dutch health care system and discuss how far these measures meet our criteria for a proper communalization. We focus in this section on the effects of these measures on family care because more and more family care plays an important role in good functioning of the health care system.

[Assertive Community Treatment for patients with a first episode psychosis. Model fidelity and specific adaptations for particular target groups]. / Assertive Community Treatment bij patiënten met een eerste psychose. Modelgetrouwheid en doelgroepspecifieke aanpassingen.

BACKGROUND: Assertive Community Treatment (ACT) is an evidence-based treatment model, which has been frequently discussed and investigated and which has been used mainly with patients suffering from 'severe mental illness'. It is a pro-active type of treatment involving a multidisciplinary team who provide outreaching and intensive care (treatment, rehabilitation and support). Increasingly, the act model is being used with other target groups such as patients with a first episode psychosis. Frequently act is not being implemented strictly in accordance with the original model. As a result, various combinations of elements of act are being presented. AIM: Primarily to find out whether the original components of act can be varied in such a way that it combines the best possible treatment procedures for the target group of patients suffering from a first episode psychosis. METHOD: Model fidelity was measured and patients and their carers were asked to state to what extent the care provided met their care requirements. The results were used for adaptations of the original model. However, it was assumed from the outset that any variations on the essential elements of the act model could undermine the fundamental principles of act and affect its efficacy. We therefore adhered to the original model as strictly as possible, looking particularly at the care requirements of patients and carers and examining which elements of the model could be used to improve the care of patients with a first episode psychosis. RESULTS AND CONCLUSION: Results show that it is possible to implement the original act model successfully and that patients and caregivers are satisfied with the model. There is strong evidence that the implementation of elements of the act in specific combinations can increase the efficacy of the act when it is applied to special groups of patients, such as those with a first episode psychosis. However, considerable care and caution are called for when act is being adapted in this way for use with special groups of patients.

Lower prevalence of heart disease but higher mortality risk during follow-up was found among nonrespondents to a cohort study.

OBJECTIVE: The primary aim was to assess the association between response behavior and health status at baseline, and survival in a 5-year follow-up period. A secondary aim was to assess whether reasons for nonresponse were associated with health status at baseline. STUDY DESIGN AND SETTING: Data came from a prospective study cohort consisting of 31,349 men and women aged 45-70 years. Objective retrospective and prospective health information derived from general practitioner registries was available for both respondents and nonrespondents. RESULTS: Results show that among respondents coronary heart disease was more prevalent. Compared with respondents, noncontacts had a higher mortality risk during follow-up. Refusals had hypercholesterolemia more often than did noncontacts, and coronary heart disease or diabetes mellitus less often. CONCLUSION: The paradoxical results that respondents are less healthy at baseline but prospectively have a lower mortality risk may point to a selection effect indicating that the 'worried ill' are more inclined to participate. This effect could imply that observed relationships between risk factors or behaviors and outcomes in cohort studies may be attenuated.

Substance use among emergency room patients: Is self-report preferable to biochemical markers?

AIM OF STUDY: To explore the validity of self-reported substance use among emergency room populations and the processes of sample selection bias, to establish their influence on the prevalence rates found. METHODS: Self-reported alcohol and illicit drug use of patients in the emergency room is compared with results from an alcohol breath analyser and urine toxicology. RESULTS: Variations in reported substance use occur when comparing self-report measures with alcohol breath analyser results and urine toxicology. Self-reported alcohol use was found among 7.5% of the patients compared with 4.7% based on alcohol breath analysers. Illicit drug use was reported by 9.0% of the patients whereas urine toxicology resulted in 30% patients positive for illicit drug use. Patients that voluntarily participate in the study differ from those that do not participate. Patients who refuse an alcohol breath analyser report slightly more alcohol use prior to the injury (difference not significant), and patients who provide a urine sample report more illicit drug use prior to the injury compared to those that refuse. DISCUSSION: Differences in prevalence rates can be explained partly by the measurements used and partly by sample selection bias. Self-reported alcohol use and self-reported illicit drug use are preferable to the "gold standard" when used among emergency room patients, because both measures provide more accurate information on the actual use. Sample selection bias also influences the prevalence rates.

A local and regional Alcohol and Drugs Monitor in the Netherlands: a tale of three cities.

Local and regional policymakers, care providers and prevention workers involved in addiction and addiction care need timely and reliable information. As few data on substance use are available at a local or regional level, an integrated local or regional monitoring system for alcohol and drugs (MAD) was developed. The MAD consists of four modules: a local social and information map, analyses of registration data of (addiction) care organisations, a local/regional survey among the general population and a community-based drug monitoring system aimed at collecting data on hard drug users. Both quantitative and qualitative research methods are used. This paper presents an overview of the MAD results with respect to alcohol and illicit drug use. Both quantitative and qualitative results show a substantial variation between regions, even in a country as small as the Netherlands. The study shows that a monitoring system can be an important source of information for local addiction policy, care and prevention.

Key concepts of demand-driven health care; an approach based on client's needs.

In most European countries we are witnessing a shift from supply-driven to demand-driven approaches in health care. According to these approaches, health care should contribute to the fulfillment of health-care-related needs of individuals and, therefore, to their perceived quality of life. The purpose of this study is to develop a conceptual framework for research in this new view of health care. The authors conclude that the 'felt need' should be the foundation of demand-driven care. The second part of the study is based on a widely used behavioral model resulting in a conceptual framework for research, policy and practice. This study makes a start at providing information about fundamental concepts that are at the heart of the demand-driven approach. In order to contribute to quality of life, health care providers should explore the underlying needs while developing services in order to fit the demand-driven approach.

Are epidemiological and sociological surveys a proper instrument for detecting true problem drinkers? (The low sensitivity of an alcohol survey in Rotterdam).

The sensitivity of an alcohol survey in Rotterdam is estimated at only 16%. Taking account of sampling fluctuations, an upper confidence limit of 47% for the sensitivity can be computed. The statistical procedure is not based upon interviewing true problem drinkers to be identified from registers, but upon an anonymous verification of positively scoring individuals and a sample of negatively scoring individuals in the survey with registers of true problem drinkers. The above results may have implications for the interpretation of survey based prevalence figures.

The Dutch instant lottery: prevalence and correlates of at-risk playing.

After a long and contentious political debate, the instant lottery was introduced in the Netherlands in 1994. One of the conditions for allowing the introduction was that an evaluation study should be conducted with regard to possible negative side effects of the instant lottery in terms of excessive playing or addiction. This article reports on the main results of this evaluation study. In a random sample of 4497 instant lottery players, at-risk players were differentiated from recreative players on the basis of level of involvement in the instant lottery, impaired control and the experienced negative consequences of playing. Of the sample, 4.1% could be classified as an at-risk player. Actual problems resulting from playing in the instant lottery were experienced by 0.7% of the players. At-risk players and recreative players did not only differ substantially in their playing behaviour, but also with regard to their socio-economic background, playing motivation, participation in other games of chance, and involvement in alcohol use and use of marijuana. To summarize, at-risk players were more likely to come from a poor socio-economic background, to play the instant lottery with a negative playing motivation, to be heavily involved in other forms of gambling, to have used marijuana and to drink alcohol excessively.

Gender differences in alcohol-related problems: controlling for drinking behaviour.

AIMS: Two hypotheses were tested to explain a high prevalence of alcohol-related problems among women relative to their low prevalence of excessive drinking: (1) At a given level of drinking, women may report more problems of any type than do men. (2) At a given level of drinking, the number of problems or the severity of the reported problems may be lower among women than among men. DESIGN: General population survey. SETTING: Rotterdam, The Netherlands. PARTICIPANTS: 3537 Dutch respondents within the age range 16-69 years. MEASUREMENTS: Alcohol-related problems were measured in five problem areas: psychological dependence, symptomatic drinking, social problems, health problems/accidents and frequent drunkenness/hangovers. A problem index was formed by adding up the scores in the five separate problem areas. Alcohol use was measured by the Quantity-Frequency-Variability index. FINDINGS: For the same level of drinking, women were as likely as men to report alcohol-related problems except that women light drinkers were actually less likely to report problems than men. Men tended to have a greater accumulation of different types of problems within drinking categories than women. Overall problem severity, however, did not differ between men and women. The apparent excess prevalence of alcohol problems in women relative to drinking level appears to be due to presence of problems even among light drinkers and a greater preponderance of light drinkers in women than men. CONCLUSIONS: The first hypothesis was rejected; drinking levels being the same, the level of alcohol problems is the same or even lower for women than for men. As hypothesized, men tend to have a greater accumulation of different kinds of problems than women. However, the severity of the reported problems does not differ between men and women.

Drinking patterns and health outcomes: occasional versus regular drinking.

AIMS: To compare the health of drinkers with different drinking patterns and particularly drinkers with comparable average intakes and different drinking frequency. SETTING: General population survey conduced in Eindhoven, the Netherlands (n = 18,973). MEASUREMENTS: Chronic conditions, perceived general health, and health complaints were the outcome measures. Drinking categories were constructed by taking into account the frequency and amount of alcohol consumption (up to six glasses per sitting). FINDINGS: Drinking 3-5 days per week/3-5 glasses per occasion and drinking 6-7 days/1-2 glasses were associated with lower likelihood for reporting health complaints and for perceiving one's health as less than good compared to those drinking 1-2 days/1-2 glasses (reference group). Drinking 1-2 days/6 glasses was associated with being more likely to report chronic conditions, compared to the reference group. Those drinking 1-2 days/6 glasses were significantly more likely to report > 3 health complaints than those drinking 6-7 days/1-2 glasses. Although no differences were observed for any of the other comparison groups, at high levels of consumption (18-35 units/week), occasional drinkers (3-5 days/6 glasses) seemed to have better health outcomes compared to their counterparts (6-7 days/3-5 glasses). CONCLUSION: In addition to average alcohol intake, drinking pattern is also related to health.

Health of migrants and migrant health policy, The Netherlands as an example.

In The Netherlands, as in many other countries, many studies have addressed the health situation of migrant groups. After a discussion on methodological pitfalls in migrant studies, the article reviews the most important results. The data show that there are differences in the health status and mortality patterns between migrant groups and the indigenous population. Most, but not all, of the differences are in disfavour of ethnic groups. Possible determinants of these differences are evident in socio/cultural, genetic and socio-economic factors. A model is presented that demonstrates the relation between these factors and health and disease. Implications for research and for health policy are discussed.

The geographic relationship between alcohol use, bars, liquor shops and traffic injuries in Rotterdam.

Within the scope of the World Health Organization's program "Health for All by the Year 2000," a health information system for Rotterdam neighborhoods was developed. Through this information system, among others, data on geographic distribution of alcohol use, bars, liquor shops and traffic accidents are collected. Research has been done on the geographic relationship between the percentage of alcohol users and numbers of bars, liquor shops and traffic injuries. Significant correlations were found between the percentage of alcohol users and traffic injuries per neighborhood, the number of bars and traffic injuries per neighborhood and the percentage of alcohol users and number of liquor shops per neighborhood. Although confounding of the data occurs, the observed relations can be logically explained. Knowledge of the geographic relation between alcohol use, traffic injuries and number of bars can be useful for further development of multi-sectoral health policies.

The U-shaped curve: various health measures and alcohol drinking patterns.

OBJECTIVE: To determine whether the well-known U-shaped relationship between average alcohol intake and mortality also holds for other health measures and for aspects of drinking other than weekly average alcohol intake, such as frequency of heavy-drinking episodes. METHOD: This study was carried out within the framework of a general population survey conducted in Eindhoven, The Netherlands (N = 18,973). Apart from mortality, the following health measures were considered: self-assessed health (based on perceived general health and the Nottingham Health Profile questionnaire), a list of chronic conditions and a list of health complaints. Respondents were categorized as abstainers, light (1-14 units/week), moderate (15-28 units/week) and excessive drinkers (> or =29 units/week). Information on the frequency with which heavy-drinking episodes occurred was also available. RESULTS: Light or moderate drinkers had not only lower mortality but other health burdens were lower than for either abstainers or heavier drinkers. Frequent heavy-drinking episodes were observed to be directly related to increased mortality rates, although not significantly. A trend was observed for drinkers reporting seldom heavy-drinking episodes (once or twice in the previous 6 months) to report less health burdens and to have lower mortality rates than those reporting no heavy drinking episodes. CONCLUSIONS: A U-shaped pattern was observed for mortality as well as for several other health measures. Frequent heavy-drinking episodes were related to an increased likelihood of mortality (not significant but suggesting a J-shaped pattern) and were not related to other health measures.

Alcohol consumption and alcohol control policy: the case of the Netherlands.

In the last decades the Netherlands have experienced a strong increase in heavy drinking, alcohol-related morbidity and, to a lesser extent, alcohol-related mortality. Along with an increase in leisure time and income, it is possible that two more specific factors contributed to these developments in alcohol consumption, i.e. catching up with the drinking habits of neighbouring countries and a process of secularization. The strong increases mentioned have until recently not provoked any strong negative reactions, either from the public at large or from the government. Moreover, the Dutch government has no tradition in developing and implementing a restrictive alcohol policy. In two large-scale studies in Rotterdam and Limburg we have found that in the population at large, there are, with one exception, no strong sentiments in favor of or against concrete preventive measures. We argue that an effective prevention policy is necessary, which should at least contain the following elements: (1) a public health campaign to support the implementation of possible restrictive measures; (2) measures aimed at a stabilization or reduction of the per capita consumption; (3) specific preventive measures for high risk groups; and (4) a social and political structure which facilitates the formulation and implementation of a prevention policy.

Profiles of heroin addicts in different treatment conditions and in the community.

This article describes profiles of heroin addicts in three types of treatment (methadone, detox and therapeutic community) and those not in treatment in the local community. The profiles are based on data at item-level of the revised Addiction Severity Index. In total, 310 heroin addicts were interviewed. The results show that on the one hand the community group and the methadone group are roughly comparable, and on the other hand the detox and therapeutic community groups have similar characteristics. The latter groups report significantly more psychological and social problems. The community group mentions the fewest problems with drug use and more illegal activities in the past month. The results indicate that large differences exist between the groups in psychosocial problems. Furthermore, they indicate that the methadone group has no specific pattern of problems. Two important groups outside treatment are identified with respect to matching: addicts under 25 years old and addicts with a non-Dutch cultural background.