No. 245-Alcohol Use and Pregnancy Consensus Clinical Guidelines.

OBJECTIVE: To establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence. EVIDENCE: Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. VALUES: The quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: The Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada. ENDORSEMENT: These consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk. SUMMARY STATEMENTS: RECOMMENDATIONS.

Efficacy of a physicians' pocket guide about prenatal substance use: a randomized trial.

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.

Alcohol use and pregnancy consensus clinical guidelines.

OBJECTIVE: to establish national standards of care for the screening and recording of alcohol use and counselling on alcohol use of women of child-bearing age and pregnant women based on the most up-to-date evidence. EVIDENCE: published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in May 2009 using appropriate controlled vocabulary (e.g., pregnancy complications, alcohol drinking, prenatal care) and key words (e.g., pregnancy, alcohol consumption, risk reduction). Results were restricted to literature published in the last five years with the following research designs: systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment (HTA) and HTA-related agencies, national and international medical specialty societies, clinical practice guideline collections, and clinical trial registries. Each article was screened for relevance and the full text acquired if determined to be relevant. The evidence obtained was reviewed and evaluated by the members of the Expert Workgroup established by the Society of Obstetricians and Gynaecologists of Canada. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. VALUES: the quality of evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: the Public Health Agency of Canada and the Society of Obstetricians and Gynaecologists of Canada. ENDORSEMENT: these consensus guidelines have been endorsed by the Association of Obstetricians and Gynecologists of Quebec; the Canadian Association of Midwives; the Canadian Association of Perinatal, Women's Health and Neonatal Nurses (CAPWHN); the College of Family Physicians of Canada; the Federation of Medical Women of Canada; the Society of Rural Physicians of Canada; and Motherisk. SUMMARY STATEMENTS: 1. There is evidence that alcohol consumption in pregnancy can cause fetal harm. (II-2) There is insufficient evidence regarding fetal safety or harm at low levels of alcohol consumption in pregnancy. (III) 2. There is insufficient evidence to define any threshold for low-level drinking in pregnancy. (III) 3. Abstinence is the prudent choice for a woman who is or might become pregnant. (III) 4. Intensive culture-, gender-, and family-appropriate interventions need to be available and accessible for women with problematic drinking and/or alcohol dependence. (II-2). RECOMMENDATIONS: 1. Universal screening for alcohol consumption should be done periodically for all pregnant women and women of child-bearing age. Ideally, at-risk drinking could be identified before pregnancy, allowing for change. (II-2B) 2. Health care providers should create a safe environment for women to report alcohol consumption. (III-A) 3. The public should be informed that alcohol screening and support for women at risk is part of routine women's health care. (III-A) 4. Health care providers should be aware of the risk factors associated with alcohol use in women of reproductive age. (III-B) 5. Brief interventions are effective and should be provided by health care providers for women with at-risk drinking. (II-2B) 6. If a woman continues to use alcohol during pregnancy, harm reduction/treatment strategies should be encouraged. (II-2B) 7. Pregnant women should be given priority access to withdrawal management and treatment. (III-A) 8. Health care providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication for termination of pregnancy. (II-2A).

Short-term outcomes in patients attending a primary care-based addiction shared care program.

OBJECTIVE: To evaluate patient outcomes in an addiction shared care program that is managed by family physicians working in a primary care setting. DESIGN: Prospective cohort study. SETTING: The addiction shared care program at St Joseph's Health Centre in Toronto, Ont, which is staffed by a nurse clinician, an addiction therapist, a clinical fellow, and 6 family physicians in an academic family medicine unit. PARTICIPANTS: Participants included patients who attended at least one session in the program. The patients were self-referred or referred by family doctors, government agencies, or the emergency department. INTERVENTIONS: The service provided brief counseling interventions, outpatient medical detoxification, pharmacotherapy, and follow-up, and there was communication with the referring family physicians. MAIN OUTCOME MEASURES: Changes in self-reported substance use were measured through interviews at intake and at 3 to 4 months after the initial office visit. RESULTS: The study was conducted between January 2005 and April 2006. Out of 204 patients who gave consent to participate at baseline, we interviewed 71 patients about 4 months later. Among 33 problem drinkers, the mean number of standard drinks consumed per week declined from 32.9 at baseline to 9.6 at follow-up (P < .0005). Of the 29 problem opioid users, 6 were started on methadone treatment and 13 had decreased their opioid consumption from a mean morphine equivalent of 168.38 mg to 70.85 mg daily (P = .001). There was also a significant decline in the problematic use of benzodiazepines (P = .004) and other drugs (P = .005), but there was no significant decline in the problematic use of cannabis or cocaine. Twenty-two patients (31%) participated in Alcoholics Anonymous or formal addiction treatment. CONCLUSION: Shared care is a promising new strategy for delivering addiction intervention. Further evaluation is warranted, with more complete follow-up and objective outcome measures.

Effects of a distance learning program on physicians' opioid- and benzodiazepine-prescribing skills.

INTRODUCTION: Opioid misuse is common among patients with chronic nonmalignant pain. There is a pressing need for physicians to increase their confidence and competence in managing these patients. METHODS: A randomized controlled trial of family physicians (N = 88) attending 1 of 4 continuing medical education events helped to determine the effectiveness of e-mail case discussions in changing physician behavior. Before random assignment, participants completed a pretest and attended a 3-hour didactic session on prescribing opioids and benzodiazepines. The intervention group participated in 10 weeks of e-mail case discussions, with designated participants responding to questions on cases. An addictions physician facilitated the discussion. Several months after the e-mail discussion, participants took part in a mock telephone consultation; a blinded researcher posing as a medical colleague asked for advice about 2 cases involving opioid and benzodiazepine prescribing. Using a checklist, the researcher recorded the questions asked and advice given by the physician. RESULTS: On post-testing, both groups expressed greater optimism about treatment outcomes and were more likely to report using a treatment contract and providing advice about sleep hygiene. There were no significant differences between pretesting and post-testing between the groups on the survey. During the telephone consultation, the intervention group asked significantly more questions and offered more advice than the control group (odds ratio for question items, 1.27 [p = .03]; advice items, 1.33 [p = .01). DISCUSSION: Facilitated by electronic mail and a medical expert, case discussion is an effective means of improving physician performance. Telephone consultation holds promise as a method for evaluating physicians' assessment and management skills.

The use of the Antenatal Psychosocial Health Assessment (ALPHA) tool in the detection of psychosocial risk factors for postpartum depression: a randomized controlled trial.

OBJECTIVE: Eliciting known risk factors for postpartum depression (PPD) during pregnancy may enable primary health care providers to identify women at increased risk of becoming depressed. The purpose of this study was to examine how well the Antenatal Psychosocial Health Assessment (ALPHA) form identified antenatal risk factors for PPD, compared with routine care, in a sample of pregnant women. METHODS: A randomized controlled trial was conducted to assess the effectiveness of the ALPHA form in detecting antenatal risk factors associated with the adverse postpartum outcomes of postpartum depression, intimate partner violence, child abuse, and couple dysfunction. The participants were primary antenatal care providers--family physicians, obstetricians, and midwives--from four diverse communities in Ontario. These providers were matched and then randomly allocated into the intervention group, who used the ALPHA form, or into the control group, who administered usual care. In total, 227 pregnant women were recruited: 98 in the ALPHA group and 129 in the control group. The data presented in this paper are from a secondary analysis focusing on PPD as the outcome. RESULTS: Providers randomized to the ALPHA group identified a statistically significantly higher proportion of women with antenatal psychosocial risk factors for PPD (36% vs. 26%) and a significantly higher number of risk factors per woman compared with the control group (mean 2.1 vs.1.8) (z = -1.96, P = 0.05). Providers in the ALPHA group also identified significantly more women having a "previous history of depression" (16% vs. 6%) (chi2 = 5.243, df = 1, P = 0.03) and "[having] witnessed or experienced abuse as a child" (17% vs. 3%) (chi2 = 12.488, df = 1, P = 0.0005), which are both established risk factors for PPD. CONCLUSION: The ALPHA provides a systematic means of eliciting antenatal psychosocial risk factors for PPD for primary care providers, and it may be particularly useful for raising and discussing sensitive issues. The detection of depressive symptomatology during pregnancy remains problematic, however, and detection may be improved by administering a simple standardized measure of depressive symptomatology during routine antenatal care.

Misuse of and dependence on opioids: study of chronic pain patients.

OBJECTIVE: To review the evidence on identifying and managing misuse of and dependence on opioids among primary care patients with chronic pain. QUALITY OF EVIDENCE: MEDLINE was searched using such terms as "opioid misuse" and "addiction." The few studies on the prevalence of opioid dependence in primary care populations were based on retrospective chart reviews (level II evidence). Most recommendations regarding identification and management of opioid misuse in primary care are based on expert opinion (level III evidence). MAIN MESSAGE: Physicians should ask all patients receiving opioid therapy about current, past, and family history of addiction. Physicians should take "universal precautions" that include careful prescribing and ongoing vigilance for signs of misuse. Patients suspected of opioid misuse can be treated with a time-limited trial of structured opioid therapy if they are not acquiring opioids from other sources. The trial should consist of daily to weekly dispensing, regular urine testing, and tapering of doses of opioids. If the trial fails or is not indicated, patients should be referred for methadone or buprenorphine treatment. CONCLUSION: Misuse of and dependence on opioids can be identified and managed successfully in primary care.

Opioids for managing chronic non-malignant pain: safe and effective prescribing.

OBJECTIVE: To review the evidence on safe and effective prescribing of opioids for chronic non-malignant pain. QUALITY OF EVIDENCE: MEDLINE was searched using the terms "opioid effectiveness" and "adverse effects." There is strong evidence that opioids are effective for both nociceptive and neuropathic pain, but limited evidence that they are effective for pain disorder. There is little information on their effectiveness at high doses or on the adverse effects of high doses. MAIN MESSAGE: Opioids should be initiated after an adequate trial of acetaminophen or nonsteroidal anti-inflammatory drugs for nociceptive pain and of tricyclic antidepressants or anticonvulsants for neuropathic pain. Patients should be asked to sign treatment agreements and to give informed consent to treatment. Patients should experience a graded analgesic response with each dose increase. Titrate doses of immediate-release opioids slowly upward until pain reduction is achieved, and then switch patients to controlled-release opioids. Most patients with chronic non-malignant pain can be managed with<300 mg/d of morphine (or equivalent). CONCLUSION: Opioids are safe and effective for managing chronic pain.

Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: a randomized controlled trial.

BACKGROUND: A pregnant woman's psychological health is a significant predictor of postpartum outcomes. The Antenatal Psychosocial Health Assessment (ALPHA) form incorporates 15 risk factors associated with poor postpartum outcomes of woman abuse, child abuse, postpartum depression and couple dysfunction. We sought to determine whether health care providers using the ALPHA form detected more antenatal psychosocial concerns among pregnant women than providers practising usual prenatal care. METHODS: A randomized controlled trial was conducted in 4 communities in Ontario. Family physicians, obstetricians and midwives who see at least 10 prenatal patients a year enrolled 5 eligible women each. Providers in the intervention group attended an educational workshop on using the ALPHA form and completed the form with enrolled women. The control group provided usual care. After the women delivered, both groups of providers identified concerns related to the 15 risk factors on the ALPHA form for each patient and rated the level of concern. The primary outcome was the number of psychosocial concerns identified. Results were controlled for clustering. RESULTS: There were 21 (44%) providers randomly assigned to the ALPHA group and 27 (56%) to the control group. A total of 227 patients participated: 98 (43%) in the ALPHA group and 129 (57%) in the control group. ALPHA group providers were more likely than control group providers to identify psychosocial concerns (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.0; p = 0.02) and to rate the level of concern as "high" (OR 4.8, 95% CI 1.1-20.2; p = 0.03). ALPHA group providers were also more likely to detect concerns related to family violence (OR 4.8, 95% CI 1.9-12.3; p = 0.001). INTERPRETATION: Using the ALPHA form helped health care providers detect more psychosocial risk factors for poor postpartum outcomes, especially those related to family violence. It is a useful prenatal tool, identifying women who would benefit from additional support and interventions.

From research to application: the development of an antenatal psychosocial health assessment tool.

OBJECTIVE: To describe the development of an assessment tool for antenatal psychosocial risk factors associated with poor postpartum outcomes. METHODS: A survey of Ontario family physicians established a need for an antenatal psychosocial health assessment (ALPHA) form. A critical literature review identified important antenatal factors for inclusion on the form. Focus groups of obstetrical care providers indicated acceptance of the provider-completed ALPHA; their feedback led to the development of a self-report ALPHA. Satisfaction, yield and reliability of the self-report and provider-completed ALPHA forms were studied and found to be comparable. RESULTS: Physicians and patients reported good satisfaction and usefulness of the ALPHA form in identifying antenatal psychosocial risk factors. The provider ALPHA was further tested in clinical practice. ALPHA endorsement was obtained from physicians, nurses and midwives. CONCLUSION: A program planning process, which included multidisciplinary involvement, evaluation and endorsement by professional organizations, aided the development, refinement and application of the ALPHA forms as primary care tools. ALPHA topic headings are incorporated into the official 2000 Ontario Antenatal Record and the ALPHA adopted for use on Prince Edward Island.

Faculty Rating of Learning Objectives for an Undergraduate Medical Curriculum in Substance Abuse.

The purpose of this study is to describe medical faculty's ratings of learning objectives related to substance abuse. A comprehensive set of learning objectives was drafted. The Associate Dean at each of Ontario's five medical schools was asked to select two faculty members from each clinical discipline who were involved in undergraduate medical education. The selected faculty were sent a survey asking them to rate 282 objectives according to their importance for undergraduate education in their discipline, using a 5-point scale. Sixty-eight out of 90 surveys were returned. For statistical analysis, disciplines were placed into two groups, Group 1 (internal medicine, surgery, emergency medicine, and anesthesia) and Group 2 (family medicine, psychiatry, and pediatrics). The mean ratings of Group 1 were significantly higher than Group 2 (p < 0.001) for five sets of objectives: attitudes, epidemiology, screening and assessment, nonmedical interventions, and specific populations (women, the elderly, and adolescents). Group 1 gave mean ratings above 4 to all themes except epidemiology, inpatient care, and medical complications. In contrast, Group 2 gave mean ratings above 4 to only three themes: physician substance abuse problems, withdrawal, and medical complications. The marked differences in learning objectives between disciplines suggest that a discipline-specific approach is needed for curricular development in substance abuse.

Participant perception of an integrated program for substance abuse in pregnancy.

OBJECTIVE: To assess participant perception of an integrated model of care for substance abuse in pregnancy. DESIGN: Focus groups were employed for this qualitative study. SETTING: Two Family Medicine Units, 1 in Toronto and 1 in Montreal, where integrated care for licit and illicit substance abuse in pregnancy is provided by a team of doctors, nurses, nurse practitioners, and social workers. PARTICIPANTS: Women who had received addiction and prenatal care at 1 of the 2 sites. METHODS: Women were asked to discuss their experiences of care in focus groups. RESULTS: Five central themes emerged: judgment, physician-patient communication, team communication, support groups, and self-responsibility. CONCLUSION: Women felt more comfortable with provider teams that shared a consistent nonjudgmental attitude.

Screening and recording of alcohol use among women of child-bearing age and pregnant women.

A woman's alcohol use during pregnancy is one of the top preventable causes of birth defects and developmental disabilities that are known as fetal alcohol spectrum disorders (FASD). The social and economic burden of FASD is substantial. Lifetime direct tangible costs per individual related to health care, education and social services in Canada have been estimated to be $1.4 million. Screening women of child-bearing age and pregnant women and recording their alcohol consumption is a practical process to identify and evaluate women at-risk and to identify potentially exposed infants. The FASD Advisory Workgroup proposes the following three levels of screenings which should be done on consenting women: Level I screening involves practice-based approaches that can be used by health care providers when talking to women about alcohol use, such as motivational interviewing and supportive dialogue. Level II screening includes a number of structured questionnaires that can be used with direct questioning (TLFB) or indirect /masked screening (AUDIT, BMAST / SMAST, CAGE, CRAFFT, T-ACE, TWEAK). Level III screening includes laboratory-based tools that can be used to confirm the presence of a drug, its level of exposure and determine the presence of multiple drugs. There are challenges and limitations in the use of the screening and assessment tools outlined. For example, the single question about alcohol use and the various questionnaires rely on a woman to provide details about her alcohol use. There is no consensus on the appropriate screening to use across Canada as each provincial / territorial jurisdiction, health care organization and healthcare provider uses a variety of formal and informal screening tool. In addition, there are inconsistent processes across Canada for the recording of the alcohol use in a woman's chart and the transfer of the information to the infant and the child's health records. The FASD Advisory Workgroup proposes eleven recommendations to improve the screening and recording processes for alcohol use in women of child-bearing age and pregnant women.

Medical students' experiences with addicted patients: a web-based survey.

UNLABELLED: Project CREATE was an initiative to strengthen undergraduate medical education in addictions. As part of a needs assessment, forty-six medical students at Ontario's five medical schools completed a bi-weekly, interactive web-based survey about addiction-related learning events. In all, 704 unique events were recorded, for an average of 16.7 entries per student. The most commonly discussed topic was alcohol withdrawal and the complications of alcohol use. The most common learning venues were lectures and clinical encounters in the emergency department or hospital. The proportion of advice-related topics (e.g., advice to drinkers and smokers) to advice plus non-advice related topics (e.g., medical complications) was greater for outpatient and community settings than for acute care and didactic settings (ratio 1.29, chi sq 15.85, p < 0.01). Students reacted strongly to the psychosocial impact of addictions on patients, yet they viewed addiction as a personal choice, not an illness. CONCLUSION: Medical students are not being trained to diagnose addiction or provide advice and counseling. Medical schools need to provide students with positive clinical experiences supervised by physicians experienced in addictions.

Medical students' knowledge about alcohol and drug problems: results of the medical council of Canada examination.

PURPOSE: To determine knowledge of a national sample of medical students about substance withdrawal, screening and early intervention, medical and psychiatric complications of addiction, and treatment options. METHODS: Based on learning objectives developed by medical faculty, twenty-two questions on addictions were included in the 1998 Canadian licensing examination. RESULTS: The exam was written by 858 medical students. The average score on the addiction questions was 64%. Students showed strong knowledge of the clinical features of medical complications. Specific knowledge gaps were identified for withdrawal treatment protocols, low-risk drinking guidelines, taking an alcohol history, substance-induced psychiatric disorders, and Alcoholics Anonymous. CONCLUSION: Medical students are knowledge-deficient around key learning objectives in addictions. The deficiencies were in areas of basic knowledge that could be learnt with little difficulty.

The Impact of SARS on Childbirth Education.

The SARS (Severe Acute Respiratory Syndrome) crisis in Toronto in the spring of 2003 had major consequences for prenatal learners. Classes in hospitals were cancelled; many couples were left without any prenatal education. This paper outlines the decision-making process of one programme that was determined to keep classes open. The impact of SARS on hospital procedures is also described. Childbirth educators are encouraged to prepare for future public health emergencies. Strategies to prepare for conducting childbirth education classes during times of crisis are outlined.

Assessing antenatal psychosocial health. Randomized controlled trial of two versions of the ALPHA form.

OBJECTIVE: To determine whether participants preferred a provider-completed or self-reported antenatal psychosocial health assessment (ALPHA) form, to evaluate the forms' effectiveness in facilitating disclosure of psychosocial issues, and to determine whether different providers gathered different information. DESIGN: Randomized controlled study. SETTING: Offices of family physicians and public health nurses (PHNs) in three health regions on Prince Edward Island. PARTICIPANTS: Physicians, PHNs, and 76 pregnant women. INTERVENTIONS: Participants completed one form and a questionnaire on theirexperience. Providers were also interviewed. MAIN OUTCOME MEASURES: Suitability and effectiveness of the forms and frequency of issues disclosed by type of form and provider. RESULTS: Most participants would recommend routine use of the ALPHA form for all pregnant women. Of the 238 psychosocial issues disclosed, significantly more were disclosed to physicians than to PHNs. CONCLUSION: Both forms were acceptable to women and providers (no clear preference emerged) and were effective at gathering information. Physicians gathered significantly more information than PHNs.