Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients.

SETTING: Alcohol use, tuberculosis (TB) drug resistance and human immunodeficiency virus (HIV) risk behavior are of increasing concern in Russian TB patients. DESIGN: A prevalence study of alcohol use and HIV risk behavior was conducted in a sample of 200 adult men and women admitted to TB hospitals in St Petersburg and Ivanovo, Russia. RESULTS: Of the subjects, 72% were men. The mean age was 41. Active TB was diagnosed using a combination of chest X-ray, sputum smears and sputum cultures. Sixty-two per cent met DSM-IV criteria for current alcohol abuse or dependence. Drug use was uncommon, with only two patients reporting recent intravenous heroin use. There was one case of HIV infection. The mean total risk assessment battery score was 3.4. Depression was present in 60% of the sample, with 17% severely depressed. Alcohol abuse/dependence was associated with an eight-fold increase in drug resistance (OR 8.58; 95% CI 2.09-35.32). Patients with relapsing or chronic TB were more likely to meet the criteria for alcohol abuse/dependence (OR 2.56; 95% CI 1.0-6.54). CONCLUSION: Alcohol use disorders are common in patients being treated for active TB, and are associated with significant morbidity. Additional surveys are needed to examine the relationship between alcohol use disorders and anti-tuberculosis drug resistance.

Treatment of intractable hiccups with intramuscular haloperidol.

Two patients with intractable hiccups were treated with intramuscular haloperidol; remission occurred within 1 hour. With its rapid action and low incidence of adverse effects, intramuscular haloperidol should be considered a therapeutic alternative in the treatment of intractable hiccups.

Improving pediatric residents' alcohol and other drug use clinical skills: use of an experiential curriculum.

OBJECTIVE: To evaluate the effectiveness of an experiential alcohol and other drug curriculum on pediatric residents' knowledge, attitudes, and skills in alcohol and other drug (AOD) issues. DESIGN: Nonrandomized control trial. SETTING: Two university pediatric residency programs. PARTICIPANTS: Pediatric residents (n = 44). INTERVENTION: Intervention residents received an experiential AOD curriculum consisting of participation in an adolescent assessment program, interactive didactic sessions, role-playing practice, and interviewing skills sessions. The control group received no formal training. MAIN OUTCOME MEASURES: Pretesting and posttesting each group using written and Objective Structured Clinical Examination evaluations using standardized patients. Evaluations were videotaped and scored by an expert panel using a standardized scoring process. RESULTS: Pretest comparisons of written knowledge and clinical skills as assessed by the Objective Structured Clinical Evaluation showed no significant differences between the intervention and the control groups. Analysis of written test scores revealed that residents' general knowledge as well as knowledge of screening techniques and management resources related to AOD issues increased significantly more for the intervention group than for the control group from pretest to posttest (P < .001). Evaluation of the videotapes showed significant improvement for the intervention group compared with controls in overall score and in the use of specific screening techniques and interviewing skills (P < .05). Self-assessment of residents' interest, confidence, and competence in AOD issues improved significantly for intervention residents vs controls (P < .05). CONCLUSIONS: Pediatric residents receiving an experiential AOD curriculum increased their knowledge and clinical skills in AOD issues significantly more than residents receiving no formal training. Similar curricula and evaluation could be used by other primary care residency programs and could be implemented in other areas of adolescent health risk behaviors.

Liver transplantation for alcoholic liver disease.

BACKGROUND: Alcoholism is the leading cause of end-stage liver failure in the United States, but the application of liver transplantation to the treatment of alcoholic liver disease remains controversial because of medical and ethical concerns. Information about the outcome of patients who undergo transplantation for alcoholic cirrhosis would help to resolve these concerns. METHODS: The results of 41 patients (Group 1) with alcoholic liver disease were compared with those of patients who underwent liver transplantation for other medical problems (group 2) at this center. Thirty of the 32 survivors from group 1 and 30 matched subjects from group 2 were interviewed to assess substance dependence, recidivism, and activity level. RESULTS: Compared with control subjects, patients with alcoholic liver disease had equivalent patient and graft survival rates and achieved an equal level of postoperative health. These results were achieved even though patients with alcoholic liver disease had significantly worse liver failure and more morbidity before surgery, and one third of the patients in this group were not abstinent before transplantation. CONCLUSIONS: We conclude that patients with alcoholic liver disease merit equal consideration for liver transplantation compared with other causes of liver failure. Treatment of the addictive disorder should be included before and after surgery.

Assessment of alcohol and other drug disorders in the seriously mentally ill.

Brief assessment methods are needed to determine the presence of alcohol and drug problems in persons with severe mental illness. The purposes of this study were to determine the prevalence of alcohol and other drug problems in a rural population of 253 clients with severe mental illness and to determine the accuracy of case manager responses to specific alcohol and drug assessment questions about their clients. Clients were assessed for the presence of past and present alcohol and drug disorders by means of a face-to-face diagnostic interview. The specific questions the case managers were asked to complete were designed to assess the quantity and frequency of recent alcohol and drug use and the presence of three criteria for alcohol or drug dependence and to differentiate present versus past history of substance problems. On the basis of the Diagnostic Interview Schedule- Revised, 35 percent of the clients met current DSM-III-R alcohol or drug criteria for abuse, dependence, or both. There were differences between client and case manager reports on the clients' use of alcohol, marijuana, cocaine, narcotics, and unprescribed tranquilizers in the last year. The best predictor of a client's present alcohol or drug problem was whether the case manager thought that the client had substance use problems at some time in his or her life (sensitivity = 0.86, specificity = 0.75). This report provides additional evidence that case manager reports are a valid method of determining the prevalence of substance use problems in persons with severe mental illness.

Opioids and the treatment of chronic pain in a primary care sample.

Chronic pain is a widespread, difficult problem facing clinicians. This study assessed the current medical management of a general population of patients with chronic pain in 12 family medicine practices located throughout the state of Wisconsin. Medical record audits were conducted on a sample of 209 adults. Sixty-seven percent were female with an average age of 53 years. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% (n = 31) of the practitioners, pain scales 25% (n = 29), and urine toxicology screens 8% (n = 6). This study suggests that primary care practitioners have unique opportunities to identify and successfully treat patients with chronic pain.

A model alcohol and other drug use curriculum for pediatric residents.

While alcohol and other drug (AOD) use is a major health risk for adolescents in the United States, there is a paucity of AOD training for pediatric residents. In 1991-92, the University of Wisconsin Medical School developed an experiential, community-based AOD curriculum for pediatrics residents. The curriculum included resident participation in a community-based AOD adolescent assessment and intervention program, interactive didactic sessions, role-playing practice, and interviewing skills sessions. The residents who participated in the curriculum (n = 25) were compared with a control group (n = 19). Evaluation included pre- and post-curriculum written tests, objective structured clinical examinations, and residents' ratings of the curriculum components. The residents who participated showed significant gains in AOD knowledge, utilization of screening techniques, and clinical management skills as compared with the controls. The residents gave positive ratings to all curriculum components. This well-received curriculum can serve as a national model both for AOD education in pediatrics and for curriculum development in other areas of adolescent health-risk-taking.

Strategies to increase alcohol screening in health care settings.

Although health care settings offer an ideal opportunity for identifying people who are currently experiencing or are at risk for problems with alcohol, clinicians screen fewer than one-half of their patients for alcohol use disorders. The rate of alcohol screening may be increased, however, by applying strategies shown to promote the use of screening procedures for other medical problems, such as cancer. These strategies include group education (e.g., workshops or seminars), training given by respected colleagues (i.e., opinion leaders), performance feedback, educational outreach visits to individual physicians (i.e., academic detailing), and financial incentives or penalties. Using clinic-based system protocols (e.g., patient questionnaires) can help make the implementation of alcohol screening in clinical practice both efficient and effective. Although incorporating alcohol screening into other high-priority clinical activities and screening programs remains a challenge, routine alcohol screening as a standard of care for all patients is receiving increased acceptance.

Cigarette, alcohol and other drug use among small city pregnant adolescents.

PURPOSE: To determine the prevalence of cigarette, alcohol and other drug use and associated factors of use among predominantly Caucasian small-city pregnant adolescents, a little-studied population. METHODS: At the initial prenatal visit 117 enrollees completed a self-administered questionnaire. Patients provided urine samples for drug metabolites. Chart review determined medical provider documentation of substance use. RESULTS: Thirty-five percent of patients were positive for alcohol or other drug use by questionnaire self-report, provider report or initial urine drug screening test. Thirteen percent of patients were positive for at least one drug metabolite in the urine. Multiple logistic regression analysis indicated a model with four significant risk factors associated with pregnant adolescent alcohol and other drug use: lack of closeness with the father of the baby, neither parent in the home, patient experiencing consequences of alcohol and other drug use, and father of the baby experiencing consequences of alcohol and other drug use. CONCLUSIONS: The high prevalence of cigarette, alcohol and other drug use in this predominantly Caucasian sample was comparable to previous inner city data. Awareness of risk factors may improve identification and management of substance use among pregnant adolescents.

PIP: During May 1990-July 1991, health workers recruited 117 pregnant adolescents at two hospital-based perinatal clinics and two family practice residency clinics in Madison, Wisconsin, into a study designed to determine the prevalence of cigarette, alcohol, and other drug use among pregnant teenagers in a small US city. 68.4% of the teenagers were Caucasian. They underwent a urine drug screening for amphetamines, benzodiazepines, cannabinoids, cocaine, opiates, LSD, and phencyclidine at the initial and third-trimester visits. The provider reviewed the medical record from the initial prenatal visit detailing the history of substance abuse. Based on the self-reports, 48.3% smoked cigarettes, 8.6% drank alcohol, and 7.7% used other drugs. 12.8% of the patients tested positive for at least one drug metabolite. These prevalences were similar to those of other inner city data. The medical provider report showed that 56.3% had used tobacco, 22.7% had used alcohol, and 11.4% had used other drugs. Medical providers detected 98.2% of the cigarette smokers, 60% of the alcohol users, and only 25% of the users of other drugs. During the third-trimester visit, 8 of 81 patients (9.9%) tested positive for marijuana (6) and cocaine (2). Of these 81 teenagers, 16 were positive for other drug use either at the first- or third-trimester visits. Three tested positive for other drug use during both visits. No significant difference in the percentage of cigarette smokers between positive and negative substance users existed. Risk factors for alcohol and other drug use included: neither parent at home (odds ratio [OR] = 3.47); father of the baby not close to the pregnant teenager (OR = 10.26); father of the baby had at least one consequence related to alcohol and other drug use (OR = 3.45); and pregnant teenager had at least one consequence related to alcohol and other drug use (OR = 8.19). These findings suggest that if clinicians are aware of these risk factors, identification and management of substance use among pregnant teenagers will improve.

Characteristics of persons with severe mental illness and substance abuse in rural areas.

A cross-sectional study of 1,551 clients receiving care in ten community-based rural mental health care systems assessed problem behaviors and psychiatric symptoms among three groups of severely mentally ill clients: those with a current substance abuse problem, those with a history of substance abuse but no current problem, and those with no history of substance abuse problems. Clients with a current substance abuse problem were younger than clients who had no history of such problems and had more symptoms of anger, more trouble with the law, and more suicidal threats than clients in the other two groups.

The effectiveness of alcoholism screening in an ambulatory care setting.

Two hundred and eighty subjects in three ambulatory care clinics participated in this study designed to assess the psychometric properties of the SMAST using DSM-III criteria for alcoholism as the diagnostic standard. Eighty-two subjects (30%) who completed the NIMH Diagnostic Interview Schedule met DSM-III criteria for alcohol abuse and/or dependence. The sensitivity of the SMAST, using the generally accepted weighted cut-off score of five or greater, was .56 and the specificity was .83. An unweighted cut-off score of two or greater produced a sensitivity of .72 and a specificity of .64. The results of this study suggest that, when the SMAST is used for screening in an ambulatory care clinic population, the optimum balance of sensitivity and specificity is achieved using an unweighted cut-off score of two or greater. In addition, the alcohol subscale of the Diagnostic Interview Schedule was easy to administer and should be considered for use as the diagnostic standard in clinical settings.

Tobacco, alcohol, and drug use in a primary care sample: 90-day prevalence and associated factors.

BACKGROUND: Primary care settings are an ideal system in which to identify and treat substance use disorders. OBJECTIVE: To ascertain the prevalence of tobacco, alcohol, and drug use in the office of 88 primary care clinicians by gender, age and ethnicity. METHOD: 21,282 adults ages 18-65 completed a self-administered Health Screening Survey while participating in a trial for early alcohol treatment. RESULTS: The period prevalence of tobacco use was 27%. For alcohol: abstainers 40%, low risk drinkers 38%, at-risk drinkers 9%, problem drinkers 8%, and dependent drinkers 5%. Twenty percent of the sample reported using illicit drugs five or more times in their lifetime and 5% reported current illicit drug use. There were marked differences in alcohol use disorders by age and ethnicity. The majority of persons who smoked reported the desire to cut down or stop using tobacco. SIGNIFICANCE: This is the first report on the combined prevalence of tobacco, alcohol and drug disorders in a large sample of persons attending community-based non-academic primary care clinics. This report confirms the high prevalence of these problems and suggests that patients will accurately complete a self-administered screening test such as the Health Screening Survey. The office procedures developed for this study provide Managed Care Organizations with a system of care that can be used to screen all persons for tobacco, alcohol and drug use disorders.

Faculty orientation within departments of family medicine.

As new faculty members in a large university-based department of family medicine, the authors were struck by the absence of a structured orientation program to help new faculty enter the world of academic family medicine. In response to a perceived need for such a program, a national survey of family medicine was conducted. In addition, 50 departments of a local university and ten local businesses were surveyed. The results of this survey, as well as a conceptual framework for an orientation program, are presented.

Widowhood: a review of the social and medical implications.

Widowed women in America are a rapidly growing and expanding proportion of the population. This article reviews important research on the social changes, family relationships, and health risks associated with widowhood from the perspective of providing background for teachers of family medicine and suggesting research directions in this area. Since research indicates widowed women utilize outpatient and inpatient services more often than married individuals of either sex, family physicians have the opportunity to assist women who are facing the changes associated with the death of a life partner.

A technique for measuring family physician priorities for patient care.

Family physicians frequently choose which elements of patient care to emphasize in order to balance the idealized principles of medical care with the real constraints of medical practice. Colleagues at several residency programs agreed to help us to find out if these choices can be quantified and whether personal characteristics of respondents or the acuteness or chronicity of the patient's illness influence these priorities. Two sets of 15 forced-choice item pairs, one set in reference to chronic illness and one set in reference to acute illness, were used in the study. Responses from 346 family physicians and non-physician colleagues ranked six hypothetical elements of patient care for acute and chronic illness: continuity, comprehensiveness, family orientation, community orientation, coordination and prevention. The data were analyzed using the psychometric scaling technique of paired comparisons. The analysis yielded a set of rankings which showed that these choices were quantifiable and made with a high degree of individual consistency and greater intragroup agreement than would result from chance. Patterns of choice differed for acute and chronic illness in a manner consistent with observed clinical practice.

Faculty development in addiction medicine: project SAEFP, a one-year follow-up study.

BACKGROUND AND OBJECTIVES: The goal of Project SAEFP (Substance Abuse Education for Family Physicians, pronounced SAFE) was to increase the number of residency teaching faculty with expertise in addiction medicine. This paper reports the results of a 12-month follow-up study conducted to assess changes in residency teaching and clinical practice of 165 residency teaching faculty who participated in this project. METHODS: The Project SAEFP work group conducted a series of 5-day courses in the fall of 1990 at 10 sites around the country. The 165 faculty participants were taught how to use a set of 12 residency teaching modules that focused on clinical areas important to primary care physicians. The follow-up study consisted of a structured telephone interview. The findings were compared to previous interviews conducted before, and 3 months after, faculty participation in the course. RESULTS: The findings suggest long-term increases in the amount of teaching, clinical practice, and consultations conducted by the family medicine faculty who participated in this faculty development project. CONCLUSION: The findings of this study suggest that an intensive 5-day course using learner-centered teaching techniques can have a significant impact on primary care teaching faculty.

Prevalence of and factors associated with current and lifetime depression in older adult primary care patients.

BACKGROUND: Depression in late life is a significant health problem in the United States. This study examined the relationship between depression and alcohol, cigarette use, family history, and sociodemographic factors in older adult primary care patients. METHODS: As part of a larger clinical trial, 2,732 patients in 24 primary care offices were recruited to complete a self-administered health screening survey. Depression was assessed using Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for lifetime and current depression. RESULTS: A total of 17.8% of females and 9.4% of males age 60 and over met DSM-III-R criteria for lifetime depression; 10.6% of the females and 5.7% of the males met current depression criteria. Depression was significantly and positively correlated with female gender and family history of mental health problems and negatively correlated with social contact. CONCLUSIONS: Older adults, especially women, should be considered at elevated risk for depression when a family history of mental health problems and self-report of inadequate social connection can be established.

Creating a substance abuse network in family medicine: lessons learned.

Family practice was one of several primary care specialties awarded federal contracts in 1985 to survey substance abuse training needs. Family medicine has since excelled in creating a viable substance abuse network. Key events were the sponsorship of a fellowship program, the formation of the Society of Teachers of Family Medicine (STFM) Substance Abuse Working Group, and the working group's pursuit of externally funded projects. Tangible measures of the network's success include collective funding exceeding $7.3 million, an increase in the number of substance abuse activities at annual STFM conferences, and a nearly four-fold growth in the group's membership and collaborative publications. Key factors underlying the vitality of the network that may be generalizable include: 1) initial emphasis on training family physician faculty; 2) making optimal use of the existing administrative channels within STFM; 3) acquisition of external funding; 4) some continuity of core persons working together; 5) active networking within and outside family medicine; and 6) promotion of individual success.

Health risk taking and human immunodeficiency virus risk in collegiate female athletes.

Risky health behaviors of female intercollegiate varsity athletes and their nonathlete peers were compared. Five hundred seventy-one female university students (109 athletes and 462 nonathlete peers) at two midwestern universities completed a self-administered, anonymous questionnaire during team meetings or class sessions. Each athlete was matched with two nonathlete controls of similar age, ethnicity, and class year to test for dichotomous outcome variables. A human immunodeficiency virus (HIV) risk scale was developed to identify factors associated with increased HIV risk for all of the female participants. Measures of alcohol and other drug use were associated with HIV risk. The athletes were found to engage in significantly fewer risk-taking behaviors than the nonathletes and to be at less risk for HIV. High levels of risk behaviors generally indicated the need for increased efforts to change risky behaviors in all college women.

Screening and brief interventions for alcohol use disorders in managed care settings.

This chapter will focus on the identification and treatment of alcohol use disorders in general medical care settings in the context of managed care systems. The chapter will include the best data available on the prevalence of problem drinking, screening procedures, brief intervention ("talk therapy"), and implementation in managed care environments. The clinical protocols presented were designed for primary care clinicians working with patients seeking routine medical care. The protocol was developed for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Physicians' Guide. The four steps were designed to help clinicians to screen, to conduct a brief assessment, to provide advice and or referral and to establish follow-up procedures.