BACKGROUND: Primary health care receptionists are increasingly expected to be involved in research. However, little is known about receptionists' attitudes to research or health programmes. AIM: To examine changes in receptionists' attitudes, with different levels of training and support, towards involvement in a general practice-based trial of screening and brief alcohol intervention. METHOD: Subjects were 84 receptionists, one per practice, who assisted in the implementation of a screening and brief alcohol intervention programme. Receptionists were randomly assigned to one of three conditions: control (no training or support), training alone, and training plus ongoing telephone support. Baseline and follow-up questionnaires were used to assess changes in receptionists' attitudes. RESULTS: Of 40 items that measured receptionists' attitudes to involvement in the programme, 70% had deteriorated after three months, 20% significantly so. There was no effect of training and support condition. Receptionists' and GPs' attitudes to research and health programmes conflicted. CONCLUSION: Receptionists developed more negative views about involvement in research and health programmes over the three-month study period, regardless of level of training and support.
Greater physician confidence in treating alcoholism is associated with a higher frequency of referring alcoholic patients for treatment, but many physicians have limited experience with Alcoholics Anonymous. We implemented a brief, didactic and experiential educational intervention about AA and evaluated its effect on knowledge and attitudes, using a before-after repeated measures study design. Thirty-six first-year internal medicine resident physicians received an educational intervention, which consisted of a 45-minute lecture about AA, a visit to an AA meeting, and a 30-minute debriefing session the next day. Residents’ knowledge and attitudes were assessed by a brief written anonymous survey before and after the educational intervention. Residents reported increases in self-perceived knowledge about AA and had more favorable attitudes towards AA after the intervention. Our pilot study shows that a brief, didactic and experiential course can improve physician knowledge and attitudes about AA, and holds promise for improving physician interface with this commonly used intervention.
Alcoholics Anonymous; medical education; housestaff; alcohol dependence; internal medicine
Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A Federally funded Screening, Brief Intervention, Referral to Treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. We compared illicit drug use at intake and six months after drug screening and interventions were administered.
SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialty treatment). In this secondary analysis of the SBIRT service program, drug use data was compared at intake and at a six month follow-up, in a sample of a randomly selected population (10%) that screened positive at baseline.
Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialty treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6 month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialty treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behavior (p < 0.001) were found.
SBIRT was feasible to implement and the self-reported patient status at six months indicated significant improvements over baseline, for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
services; treatment; prescription drug abuse; preventive medicine; marijuana; cocaine; heroin; methamphetamine; CPT® codes; primary health care; trauma centers
Rates of screening, brief intervention, and referral to treatment (SBIRT) for alcohol and drug use by physicians remain low, despite evidence of efficacy. Motivational enhancement therapy (MET) may be a promising means to help physicians resolve ambivalence about intervening with alcohol and drug users and take advantage of educational opportunities. In the present study, nine internal medicine residents received brief MET prior to standard education in SBIRT. Residents’ self-reported SBIRT attitudes and behaviors were measured before the intervention and at a five week follow-up point. Changes in SBIRT attitudes and behaviors all occurred in the expected direction, although, due to the small sample size, none reached statistical significance. Results suggest that MET may enhance educational opportunities and lead to changes in SBIRT behavior.
medical education; screening; brief intervention; alcohol; drug
Screening, brief intervention, and referral to treatment (SBIRT) approaches to reducing hazardous alcohol and illicit drug use have been assessed in a variety of health care settings, including primary care, trauma centers, and emergency departments. A major methodological concern in these trials, however, is “assessment reactivity,” the hypothesized impact of intensive research assessments to reduce alcohol and drug use and thus mask the purported efficacy of the interventions under scrutiny. Thus, it has been recommended that prospective research designs take assessment reactivity into account. The present article describes the design of the National Institute on Drug Abuse Clinical Trials Network protocol, Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), which addresses the potential bias of assessment reactivity.
The protocol employs a 3-arm design. Following an initial brief screening, individuals identified as positive cases are consented, asked to provide demographic and locator information, and randomly assigned to one of the three conditions: minimal screening only, screening + assessment, or screening + assessment + brief intervention. In a two-stage process, the randomization procedure first reveals whether or not the participant will be in the minimal-screening-only condition. Participants in the other two groups receive a more extensive baseline assessment before it is revealed whether they have been randomized to also receive a brief intervention. Comparing the screening only and screening + assessment conditions will allow determination of the incremental effect of assessment reactivity.
Assessment reactivity is a potential source of bias that may reduce and/or lead to an underestimation of the purported effectiveness of brief interventions. From a methodological perspective, it needs to be accounted for in research designs. The SMART-ED design offers an approach to minimize assessment reactivity as a potential source of bias. Elucidating the role of assessment reactivity may offer insights into the mechanisms underlying SBIRT as well as suggest clinical options incorporating assessment reactivity as a treatment adjunct.
Assessment reactivity; Brief intervention; SBIRT; Clinical trials; Research design
A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.
The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.
This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.
Problem drug use; Screening; Brief Intervention and Referral to Treatment (SBIRT); Motivational Interviewing (MI); Addiction Severity Index (ASI); Safety net; Public health benefit; Cost effectiveness
The study objective was to assess the feasibility of a computerized alcohol-screening interview (CASI) program to identify at-risk alcohol users among adult emergency department (ED) patients. The study aimed to evaluate the feasibility of implementing a computerized screening, brief intervention, and referral to treatment (SBIRT) program within a busy urban ED setting, to report on accurate deployment of alcohol screening results, and to assess comprehension and satisfaction with CASI from both patient and research staff perspectives.
Research assistants (RAs) screened a convenience sample of medically stable ED patients. The RAs brought CASI to patients’ bedsides, and patients entered their own alcohol consumption data. The CASI intervention consisted of an alcohol use screening identification test, a personalized normative feedback profile, NIAAA low-risk drinking educational materials, and treatment referrals (when indicated).
Five hundred seventeen patients were enrolled. The median age of participants was 37 years (range, 21-85 years); 37% were men, 62% were Hispanic, 7% were Caucasian, 30% were African American, and 2% were multiracial. Eighty percent reported regular use of computers at home. Eighty percent of patients approached consented to participate, and 99% of those who started CASI were able to complete it. Two percent of interviews were interrupted for medical tests and procedures, however, no patients required breaks from using CASI for not feeling well. The CASI program accurately provided alcohol risk education to patients 100% of the time. Thirty-two percent of patients in the sample screened positive for at-risk drinking. Sixty percent of patients reported that CASI increased their knowledge of safe drinking limits, 39% reported some likeliness to change their alcohol use, and 28% reported some intention to consult a health care professional about their alcohol use as a result of their screening results. Ninety-three percent reported CASI was easy to use, 93% felt comfortable receiving alcohol education via computer, and 89% liked using CASI. Ninety percent of patients correctly identified their alcohol risk level after participating in CASI. With regard to research staff experience, RAs needed to provide standby assistance to patients during <1% of CASI administrations and needed to troubleshoot computer issues in 4% of interviews. The RAs distributed the correct alcohol risk normative profiles to patients 97% of the time and provided patients with treatment referrals when indicated 81% of the time. The RAs rated patients as “not bothered at all” by using CASI 94% of the time.
This study demonstrates that an ED-based computerized alcohol screening program is both acceptable to patients and effective in educating patients about their alcohol risk level. Additionally, this study demonstrates that few logistical problems related to using computers for these interventions were experienced by research staff: in most cases, staff accurately deployed alcohol risk education to patients, and in all cases, the computer provided accurate education to patients. Computer-assisted SBIRT may represent a significant time-saving measure, allowing EDs to reach larger numbers of patients for alcohol intervention without causing undue clinical burden or interruptions to clinical care. Future studies with follow-up are needed to replicate these results and assess drinking reductions post-intervention.
Computerized alcohol screening; Brief intervention; Emergency department; SBIRT
We examined rural primary care providers’ (PCPs) self-reported practices of screening, brief interventions, and referral to treatment (SBIRT) on adolescent alcohol use and examined PCPs’, adolescents’, and parents’ attitudes regarding SBIRT on adolescent alcohol use in rural clinic settings.
In 2007, we mailed surveys that inquired about alcohol-related knowledge, attitudes, and treatment practices of adolescent alcohol use to all PCPs in 8 counties in rural Pennsylvania who may have treated adolescents. We then conducted 7 focus groups of PCPs and their staffs (n = 3), adolescents (n = 2), and parents (n = 2) and analyzed the narratives using structured grounded theory, evaluating for consistent or discordant themes.
Twenty-seven PCPs from 7 counties returned the survey. While 92% of PCPs felt that routine screening for alcohol use should begin by age 14, 84% reportedly screened for alcohol use occasionally, and reportedly 32% screened all adolescent patients. The provider focus groups (n = 20 PCPs/staff) related that SBIRT for alcohol use for adolescents was not currently effective. Poor provider training, lack of alcohol screening tools, and lack of referral treatment options were identified barriers. Adolescents (n = 12) worried that physicians would not maintain confidentiality. Parents (n = 12) acknowledged a parental contribution to adolescent alcohol use. All groups indicated computer-based methods to screen for alcohol use among adolescents may facilitate PCP engagement.
Despite awareness that rural adolescent alcohol use is a significant problem, PCPs, adolescents, and parents recognize that SBIRT for adolescent alcohol use in rural PCP settings is ineffective, but it may improve with computer-based screening and intervention techniques.
Access to care; adolescents; alcohol abuse; geography; patient assessment
Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.
We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.
A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.
RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.
Alcohol consumption; Alcoholism; Inpatients; Nursing; Nurses; Implementation; Screening; Counseling; Qualitative research; Focus groups
Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although Screening, Brief Intervention, and Referral to Treatment (SBIRT) models have been extensively studied and are considered effective for individuals with alcohol problems presenting in emergency departments and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs.
This paper describes the design of a NIDA Clinical Trials Network protocol testing the efficacy of an SBIRT model in medical EDs, highlighting considerations that that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings.
The protocol is described, and critical design decisions are discussed.
Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis.
Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings.
Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.
Alcohol and drug consumption can affect judgment and may contribute towards an increased likelihood of engaging in risky sexual behaviour. In this cross sectional survey of clients attending STI services levels of drug and alcohol use were assessed using two standardised drug and alcohol screening instruments (the PAT and the SDS).
The rates of hazardous alcohol consumption were similar to those found among patients attending A&E departments. Approximately 15% of clients indicated possible dependence on alcohol or other drugs, and these clients were likely to cite their substance use as related to their attendance, and to accept the offer of help or advice.
The use of brief screening instruments as part of routine clinical practice is recommended. The STI clinic is well placed to identify substance use and to offer advice and/or onward referral to specialist services.
Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates.
In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention.
Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients.
Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.
The Patient Protection and Affordable Care Act of 2010 supports integration of substance abuse interventions and treatments into the mainstream health care system. Thus, effective screening and intervention for substance use disorders in health care settings is a priority.
This paper reviews the prevalence of alcohol and drug use disorders (abuse or dependence) in primary care settings and emergency departments, as well as current screening tools and brief interventions.
MEDLINE was searched using the following keywords: alcohol use, alcohol use disorder, drug use, drug use disorder, screening, primary care, and emergency departments. Using the related-articles link, additional articles were screened for inclusion. This review focuses on alcohol and drug use and related disorders among adults in primary care settings.
Screening, brief intervention, and referral for treatment are feasible and effective in primary care settings, provided that funding for screening is available, along with brief interventions and treatment facilities to which patients can be referred and treated promptly.
brief intervention; emergency departments
Drinking alcohol during pregnancy has a range of negative consequences for the developing fetus. Screening and brief intervention approaches have significant promise, but their population impact may be limited by a range of challenges to implementation. We, therefore, conducted preliminary acceptability and feasibility evaluation of a computer-delivered brief intervention for alcohol use during pregnancy.
Participants were 50 pregnant women who screened positive for risky drinking during a routine prenatal clinic visit and were randomly assigned to computer-delivered brief intervention or assessment-only conditions.
Ratings of intervention ease of use, helpfulness, and other factors were high (4.7–5.0 on a 1–5 scale). Participants in both conditions significantly decreased alcohol use at follow-up, with no group differences; however, birth weights for infants born to women in the intervention group were significantly higher (p<0.05, d = 0.62).
Further development and study of computer-delivered screening and intervention for alcohol use during pregnancy are warranted.
Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.
The Screening, Brief Intervention and Referral to Treatment (SBIRT) service for unhealthy alcohol use has been shown to be one of the most cost-effective medical preventive services and has been associated with long-term reductions in alcohol use and health care utilization. Recent studies also indicate that SBIRT reduces illicit drug use. In 2008 and 2009, the Substance Abuse Mental Health Service Administration funded 17 grantees to develop and implement medical residency training programs that teach residents how to provide SBIRT services for individuals with alcohol and drug misuse conditions. This paper presents the curricular activities associated with this initiative.
We used an online survey delivery application (Qualtrics) to e-mail a survey instrument developed by the project directors of 4 SBIRT residency programs to each residency grantee's director. The survey included both quantitative and qualitative data.
All 17 (100%) grantees responded. Respondents encompassed residency programs in emergency medicine, family medicine, pediatrics, obstetrics-gynecology, psychiatry, surgery, and preventive medicine. Thirteen of 17 (76%) grantee programs used both online and in-person approaches to deliver the curriculum. All 17 grantees incorporated motivational interviewing and validated screening instruments in the curriculum. As of June 2011, 2867 residents had been trained, and project directors reported all residents were incorporating SBIRT into their practices. Consistently mentioned challenges in implementing an SBIRT curriculum included finding time in residents' schedules for the modules and the need for trained faculty to verify resident competence.
The SBIRT initiative has resulted in rapid development of educational programs and a cohort of residents who utilize SBIRT in practice. Skills verification, program dissemination, and sustainability after grant funding ends remain ongoing challenges.
Recent years have seen increased diffusion of the Screening, Brief Intervention, Referral and Treatment Initiative (SBIRT) in healthcare environments. This study examined the relationship between substance use outcomes and service variables within the SBIRT model.
Over 55,000 adult patients were screened for substance misuse at rural health clinics throughout New Mexico during the SBIRT Initiative. This naturalistic pre-post services study used administrative baseline, 6 month follow-up, and services data for adult participants in the New Mexico SBIRT evaluation (n=1,208). Changes in self-reported frequency of illicit drug use, alcohol use, and alcohol intoxication were examined as a function of service level (brief intervention– BI versus brief treatment/referral– BT/RT) and number of service sessions.
Participants reported decreased frequency of illicit drug use, alcohol use, and alcohol intoxication 6 months after receipt of SBIRT services (p<.001 for each). Compared to those who received BI, participants who received BT/RT had sharper reductions in frequency of drinking (IRR=.78; p<.05) and alcohol intoxication (IRR=.75; p<.05). Number of service sessions was associated with reduced frequency of alcohol use (IRR=.84; p<.01) and intoxication (IRR=.82; p<.05), but only among those who received BI.
Substance-using patients with disparate levels of use may benefit from SBIRT. In a real-world, multi-site rural SBIRT program, services of higher intensity and (within the BI modality) frequency were associated with greater magnitude of change in drinking behaviors. Reductions in illicit drug use, while substantial, did not differ significantly based on service variables. Future studies should identify the preferred service mix in the SBIRT model as it continues to expand.
Screening; Brief Intervention; Brief Treatment; SBIRT; Services; Rural Healthcare
The incorporation of guidelines for the treatment of tobacco smoking into routine care requires positive attitudes, counselling skills and knowledge about additional help available for smokers. The study assesses performance of smoking cessation intervention, attitudes, training status and knowledge about additional help for smokers in the care for pregnant and parenting women by midwives, gynaecologists and paediatricians. A survey of all midwives, gynaecologists and paediatricians registered for primary medical care in the federal state Saarland, Germany, was conducted. Participation in the postal questionnaires was 85 %. Depending on profession, 90 % to 100 % see smoking cessation counselling as their assignment, 17 % to 80 % screen for, 48 % to 90 % document smoking status, and 55 % to 76 % offer brief or extensive counselling. 61 % to 87 % consider training to enhance their knowledge and/or counselling skills necessary. The compliance of providers with the necessity to give support in smoking cessation is very high. However, the current status of cessation counselling does not sufficiently correspond to the evidence based requirements. Reports in medical press and advanced training courses should support health care providers and establish smoking as an inherent topic of the anamnesis and treatment of current and former pregnant or parenting smokers.
Smoking cessation counselling pregnancy
INTRODUCTION AND AIMS
To explore the association between primary care professionals’ (PCPs) attitudes towards unhealthy alcohol and other drug (AOD) use (from risky use through dependence) and readiness to implement AOD-related preventive care.
DESIGN AND METHODS
PCPs from 5 health centers in Sao Paulo were invited to complete a questionnaire about preventive care and attitudes about people with unhealthy AOD use. Logistic regression models tested the association between professional satisfaction and readiness. Multiple Correspondence Analysis (MCA) assessed associations between stigmatizing attitudes and readiness.
Of 160 PCPs surveyed, 96 (60%) completed the questionnaire. Only 25% reported implementing unhealthy AOD use clinical prevention practices; and 53% did not feel ready to implement such practices. Greater satisfaction when working with people with AOD problems was significantly associated with readiness to implement AOD-related preventive care. In MCA two groups emerged: 1. PCPs ready to work with people with unhealthy AOD use, who attributed to such patients lower levels of dangerousness, blame for their condition and need for segregation from the community (suggesting less stigmatizing attitudes); 2. PCPs not ready to work with people with unhealthy AOD use, who attributed to them higher levels of dangerousness, blame, perceived level of patient control over their condition, and segregation (suggesting more stigmatizing attitudes).
DISCUSSION AND CONCLUSIONS
More stigmatizing attitudes towards people with unhealthy AOD use are associated with less readiness to implement unhealthy AOD-related preventive care. Understanding these issues is likely essential to facilitating implementation of preventive care, such as screening and brief intervention, for unhealthy AOD use.
Alcohol; Drugs; Primary Health Care; Attitudes; Stigma
OBJECTIVE: To assess the knowledge, attitudes, and behaviours of tobacco growers and allotment owners in the southeastern United States. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Tobacco growers (n = 529) and tobacco allotment owners (n = 417) were interviewed by telephone in March 1995. SETTING: Tobacco growing states in the southeastern US. MAIN OUTCOME MEASURES: Attitudes of tobacco growers and tobacco allotment owners towards, and experience with, diversification; and attitudes towards an increase in the federal excise tax on tobacco. RESULTS: Half of the respondents had done something to learn about on-farm alternatives to tobacco, had an interest in trying other on-farm ventures to supplement tobacco income, and found alternatives that were profitable. There was a strong, negative linear trend between age and being interested in or trying alternative enterprises. Structural and economic impediments to diversification were noted by respondents (especially younger respondents), but 73% supported an increase in the federal excise tax on tobacco if the money was used to help farmers overcome these barriers. CONCLUSIONS: These data suggest that farmers and health professionals have reason to establish dialogue around diversification and using excise tax increases to fund diversification and to promote health. Tobacco companies have been successful in mobilising farmers against tax increases, but efforts must be made to show farmers that tax increases can be beneficial both to their diversification efforts and to public health. The outcome of this dialogue may well affect the economic infrastructure of thousands of rural communities, the livelihood of tens of thousands of tobacco farmers and their families, and the health of millions of tobacco users.
Although screening for tobacco use is increasing with electronic health records and standard protocols, other tobacco-control activities, such as referral of patients to cessation resources, is quite low. In the QUIT-PRIMO study, an online referral portal will allow providers to enter smokers' email addresses into the system. Upon returning home, the smokers will receive automated emails providing education about tobacco cessation and encouragement to use the patient smoking cessation website (with interactive tools, educational resources, motivational email messages, secure messaging with a tobacco treatment specialist, and online support group).
The informatics system will be evaluated in a comparative effectiveness trial of 160 community-based primary care practices, cluster-randomized at the practice level. In the QUIT-PRIMO intervention, patients will be provided a paper information-prescription referral and then "e-referred" to the system. In the comparison group, patients will receive only the paper-based information-prescription referral with the website address. Once patients go to the website, they are subsequently randomized within practices to either a standard patient smoking cessation website or an augmented version with access to a tobacco treatment specialist online, motivational emails, and an online support group. We will compare intervention and control practice participation (referral rates) and patient participation (proportion referred who go to the website). We will then compare the effectiveness of the standard and augmented patient websites.
Our goal is to evaluate an integrated informatics solution to increase access to web-delivered smoking cessation support. We will analyze the impact of this integrated system in terms of process (provider e-referral and patient login) and patient outcomes (six-month smoking cessation).
Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628.
In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief intervention, and referral to treatment. MEDLINE and published reviews were used to identify relevant literature. Several brief screening methods have been shown to effectively identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the initial intervention typically focuses on education, motivation for change, and consideration of treatment options. Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes in federal and commercial insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances in clinical methods and progress on reimbursement policies have made screening and brief intervention for underage drinking more feasible in general health care practice.
BACKGROUND: The effectiveness of an evidence-based health care intervention depends on it being delivered consistently to appropriate patients. Brief alcohol intervention is known to be effective at reducing excessive drinking and its concomitant health and social problems. However, a recent implementation trial reported partial delivery of brief alcohol intervention by general practitioners (GPs) which is likely to have reduced its impact. AIM: To investigate patient-practitioner characteristics influencing brief alcohol intervention in primary care. DESIGN OF STUDY: Cross-sectional analysis of 12,814 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires. SETTING: Eighty-four GPs who had implemented a brief alcohol intervention programme in a previous trial based in the Northeast of England. METHOD: GPs were requested to screen all adults (aged over 16 years) presenting to their surgery and follow a structured protocol to give a brief intervention (five minutes of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of the screening questionnaire were collected from all practices after a three-month implementation period. RESULTS: Although AUDIT identified 4080 'risk' drinkers, only 2043 (50%) received brief intervention. Risk drinkers that were most likely to receive brief intervention were males (58%), unemployed (61%), and technically-trained patients (55%). Risk drinkers that were least likely to receive brief intervention were females (44%), students (38%), and university educated patients (46%). Logistic regression modelling showed that patients' risk status was the most influential predictor of brief intervention. Also, GPs' experience of relevant training and longer average practice consultations predicted brief intervention. However, personal characteristics relating to patients and GPs also predicted brief intervention in routine practice. CONCLUSION: Interpersonal factors relating to patients and practitioners contributed to the selective provision of brief alcohol intervention in primary care. Ways should be found to remedy this situation or the impact of this evidence-based intervention may be reduced when implemented in routine practice.
Substance use outcomes were examined for 351 youth participating in a randomized controlled trial designed to assess the efficacy of a school-based multimodal universal preventive intervention, Linking the Interests of Families and Teachers (LIFT). Frequency of any use of tobacco, alcohol, and other drugs was assessed via self-report from grades 5 through 12. Latent variable growth models specified average levels, linear, and accelerated growth. The LIFT intervention had a significant effect on reducing the rate of growth in use of tobacco and illicit drugs, particularly for girls, and had an overall impact on average levels of use of tobacco, alcohol, and illicit drugs. Average tobacco use reductions were mediated by increases in family problem solving. The intervention obtained significant indirect effects on growth in substance use through intervention effects on reduced playground aggression and increased family problem solving. The intervention was also associated with roughly a 10% reduced risk in initiating tobacco and alcohol use. Implications for future studies of multimodal preventive interventions are discussed.
substance use; adolescence; multimodal universal prevention; growth modeling; survival analyses; mediational analyses
Alcohol dependent smokers (N = 118) enrolled in an intensive outpatient substance abuse treatment program were randomized to a concurrent brief or intensive smoking cessation intervention. Brief treatment consisted of a 15-minute counseling session with 5 min follow-up. Intensive intervention consisted of three one-hour counseling sessions plus eight weeks of nicotine patch therapy. The cigarette abstinence rate, verified by breath CO, was significantly higher for intensive (27.5%) versus brief (6.6%) treatment at one month post quit date but not at six months when abstinence rates fell to 9.1% and 2.1%. Smoking treatment assignment did not significantly impact alcohol outcomes. Although intensive smoking treatment was associated with higher rates of short term tobacco abstinence, other, perhaps more intensive smoking interventions are needed to produce lasting smoking cessation in alcohol dependent smokers.
smoking; smoking cessation; nicotine; alcoholism; alcoholism treatment