Validation of the screening strategy in the NIAAA "Physicians' Guide to Helping Patients with Alcohol Problems"

OBJECTIVE

This study was undertaken to determine the diagnostic test characteristics of the alcohol screening strategy recommended in the National Institute on Alcoholism and Alcohol Abuse (NIAAA) "Physicians' Guide to Helping Patients with Alcohol Problems."

METHOD

A research interview was performed on patients who presented to one urban emergency department (N = 395; 61% women). It asked three alcohol consumption questions, the CAGE questionnaire, and about past alcohol problems. The NIAAA-recommended screen was considered positive for alcohol consumption in excess of 14 drinks per week or 4 drinks per occasion for men, or 7 drinks per week or 3 drinks per occasion for women, or a CAGE score of 1 or greater. A sample of patients (n = 250) received the Composite International Diagnostic Interview substance abuse module, a gold standard interview, to determine lifetime or prior 12-month alcohol abuse or dependence; results were adjusted for verification bias.

RESULTS

The prevalence of lifetime:alcohol abuse or dependence was 13%, for which the NIAAA strategy was 81% sensitive and 80% specific. The prevalence of alcohol abuse or dependence in the prior 12 months was 10%, for which the strategy was 83% sensitive and 84% specific. Its positive likelihood ratio exceeded that of the CAGE, augmented CAGE or consumption questions alone, and its negative likelihood ratio was the lowest.

CONCLUSIONS

The screening strategy combining alcohol consumption and CAGE questions recommended in the NIAAA "Physicians' Guide" is valid, and has superior test characteristics compared to the CAGE alone, in this predominantly black (86%) emergency department population. Its brevity and simple interpretation recommend wider dissemination of the NIAAA "Physicians' Guide," although future research should examine its test characteristics in other clinical settings and with other populations.

Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists

BACKGROUND

Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse.

METHODS

We mailed a survey to a national sample of 2000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse.

RESULTS

Of 1082 respondents (adjusted response rate, 57%), 68% reported that they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that patients will object, and fewer perceived time constraints.

CONCLUSIONS

Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations.

Benefits of linking primary medical care and substance abuse services: patient, provider, and societal perspectives

Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, we outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for suboptimal linkage and opportunities for improving linkage within the current health care system. We also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.

Improving alcoholism treatment across the spectrum of services

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

Training Community-Based Clinicians in Screening and Brief Intervention for Substance Abuse Problems: Translating Evidence into Practice

Screening and brief intervention in general health care settings are efficacious but have not been widely adopted. Our objective was to assess the effect of an educational intervention on clinicians' substance abuse-related clinical practices. The study was a telephone survey of practicing physicians, nurses, psychologists, physician's assistants, and social workers who attended a half-day continuing education course on one of four occasions. The course covered the stages of behavioral change and motivational counseling, using primarily role play with standardized patients. Of 87 course attendees, 70 (80%) completed the interview. Months to years after the course, most (91%) reported that the course made an impact on their practice. Most (78%) of respondents reported that they frequently or always asked new patients who drank alcohol a formal screening questionnaire such as the CAGE, and 94% frequently or always assessed their substance abusing patients' readiness to change. Most respondents reported that since taking the course they were more likely (1) to screen patients for alcohol or drug related problems (86%) and (2) to ask patients about their substance abuse on a follow-up visit (96%). After exposure to an active-learning half-day continuing education course, clinicians reported improvement with and high rates of desirable substance abuse-related clinical practices up to 5 years later. Continuing education efforts that incorporate active learning directed toward practicing clinicians show promise for improving rates of brief intervention for alcohol and other drug abuse.

Training Community-Based Clinicians in Screening and Brief Intervention for Substance Abuse Problems: Translating Evidence into Practice

Screening and brief intervention in general health care settings are efficacious but have not been widely adopted. Our objective was to assess the effect of an educational intervention on clinicians' substance abuse-related clinical practices. The study was a telephone survey of practicing physicians, nurses, psychologists, physician's assistants, and social workers who attended a half-day continuing education course on one of four occasions. The course covered the stages of behavioral change and motivational counseling, using primarily role play with standardized patients. Of 87 course attendees, 70 (80%) completed the interview. Months to years after the course, most (91%) reported that the course made an impact on their practice. Most (78%) of respondents reported that they frequently or always asked new patients who drank alcohol a formal screening questionnaire such as the CAGE, and 94% frequently or always assessed their substance abusing patients' readiness to change. Most respondents reported that since taking the course they were more likely (1) to screen patients for alcohol or drug related problems (86%) and (2) to ask patients about their substance abuse on a follow-up visit (96%). After exposure to an active-learning half-day continuing education course, clinicians reported improvement with and high rates of desirable substance abuse-related clinical practices up to 5 years later. Continuing education efforts that incorporate active learning directed toward practicing clinicians show promise for improving rates of brief intervention for alcohol and other drug abuse.

The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE

To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.

DESIGN

Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.

SETTING

Acute care hospitals.

PATIENTS

We studied 23,198 pneumonia hospitalizations in a statewide administrative database.

MEASUREMENTS AND MAIN RESULTS

Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p =.012). ARD-attributable increases of $1,659 ( p =.002) and $1,664 ( p =. 002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p =.188). An increase of 1 day was seen using both strategies 2 and 3 ( p =.044 and p =.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.

CONCLUSIONS

Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization.

Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists

OBJECTIVE

To describe adult primary care physicians' and psychiatrists' approach to alcohol screening and treatment, and to identify correlates of more optimal practices.

DESIGN

Cross-sectional mailed survey.

PARTICIPANTS

A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry.

MEASUREMENTS

Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales.

MAIN RESULTS

Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object.

CONCLUSIONS

Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols or offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians' screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement

Successful teaching in evidence-based medicine

OBJECTIVES

Several published articles have described the importance of exposing medical trainees to the 'new paradigm' of evidence-based medicine (EBM). Recognizing this, we sought to develop and objectively evaluate a mini-course in EBM for third-year medical students.

DESIGN

We developed a mini-course consisting of four sessions in which students learn to derive sequentially focused questions, search MEDLINE, review articles critically and apply information from the literature to specific clinical questions. To evaluate the teaching intervention, we performed a controlled educational study. Students at the intervention site (n=34) attended the EBM mini-course, while students at the control site (n=26) received more 'traditional' didactic teaching on various clinical topics. Intervention and control students were surveyed immediately before and after the mini-course to assess changes in reading and literature searching skills, as well as a tendency to use the literature to answer clinical questions.

SETTING

Boston University School of Medicine.

SUBJECTS

Third-year medical students.

RESULTS

The intervention was associated with significant changes in students' self-assessed skills and attitudes. MEDLINE and critical appraisal skills increased significantly in the intervention group relative to the control group (significance of between group differences: P=0.002 for MEDLINE and P=0.0002 for critical appraisal), as did students' tendency to use MEDLINE and original research articles to solve clinical problems (significance of between group differences: P=0.002 and P=0.0008, respectively).

CONCLUSIONS

We conclude that this brief teaching intervention in EBM has had a positive impact on student skills and attitudes at our medical school. We believe that the key elements of this intervention are (1) active student involvement, (2), clinical relevance of exercises and (3) integrated teaching targeting each of the component skills of EBM.

The value of acupuncture detoxification programs in a substance abuse treatment system

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53-0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39-0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.

Managing alcohol withdrawal in the elderly

The alcohol withdrawal syndrome is common in elderly individuals who are alcohol dependent and who decrease or stop their alcohol intake. While there have been few clinical studies to directly support or refute the hypothesis that withdrawal symptom severity, delirium and seizures increase with advancing age, several observational studies suggest that adverse functional and cognitive complications during alcohol withdrawal do occur more frequently in elderly patients. Most elderly patients with alcohol withdrawal symptoms should be considered for admission to an inpatient setting for supportive care and management. However, elderly patients with adequate social support and without significant withdrawal symptoms at presentation, comorbid illness or past history of complicated withdrawal may be suitable for outpatient management. Although over 100 drugs have been described for alcohol withdrawal treatment, there have been no studies assessing the efficacy of these drugs specifically in elderly patients. Studies in younger patients support benzodiazepines as the most efficacious therapy for reducing withdrawal symptoms and the incidence of delirium and seizure. While short-acting benzodiazepines, such as oxazepam and lorazepam, may be appropriate for elderly patients given the risk for excessive sedation from long-acting benzodiazepines, they may be less effective in preventing seizures and more prone to produce discontinuation symptoms if not tapered properly. To ensure appropriate benzodiazepine treatment, dose and frequency should be individualised with frequent monitoring, and based on validated alcohol withdrawal severity measures. Selected patients who have a history of severe or complicated withdrawal symptoms may benefit from a fixed schedule of benzodiazepine provided that medication is held for sedation. beta-Blockers, clonidine, carbamazepine and haloperidol may be used as adjunctive agents to treat symptoms not controlled by benzodiazepines. Lastly, the age of the patient should not deter clinicians from helping the patient achieve successful alcohol treatment and rehabilitation.

Evidence-based medicine and the real world: understanding the controversy

Controversy has surrounded the 'paradigm' of evidence-based medicine since its introduction in 1992 as a new approach to the teaching and practice of medicine. Here, we address two questions: (1) is evidence-based medicine a good thing?; and (2) why has so much controversy arisen? In addressing these questions, we propose that the discussion surrounding evidence-based medicine should no longer be about whether the application of evidence in clinical practice is a good thing, because it obviously is. Instead, the debate ought to focus on the more difficult question of how to enhance its acceptability among busy clinicians practising in the 'real world'. For the future, we optimistically anticipate an enhanced adoption of evidence-based medicine, as clinicians will become increasingly capable of efficiently accessing existing and forthcoming evidence resources.

Alcohol abuse and dependence in Latinos living in the United States: validation of the CAGE (4M) questions

BACKGROUND

Brief alcoholism screening questionnaires have not been adequately studied in the rapidly growing Latino population living in the United States.

OBJECTIVE

To assess (1) the prevalence of alcoholism and (2) the performance of 2 alcohol screening instruments in Latinos.

SUBJECTS AND METHODS

We performed a cross-sectional interview study in an urban teaching hospital-based primary care practice. Consecutive self-identified Latino subjects provided informed consent. All subjects were interviewed in English or Spanish using 2 alcoholism screening tools, the CAGE (or the Spanish version, the 4M), and the Alcohol Use Disorders Identification Test, and a criterion standard for the diagnosis of alcohol abuse and dependence, the Composite International Diagnostic Interview.

RESULTS

Of 210 subjects interviewed, 36% had a lifetime diagnosis of alcohol abuse or dependence by the criterion standard. Thirty-one percent were currently drinking hazardous amounts of alcohol. A CAGE (4M) score of 1 or more was 92% sensitive and 74% specific, and a score of 2 or more was 80% sensitive and 93% specific for a lifetime diagnosis of alcohol abuse or dependency. CAGE (4M) scores of 0, 2, 3, and 4 were associated with likelihood ratios (0.1, 4.8, 18.5, and 36.8, respectively) that resulted in substantial changes from pretest (36%) to posttest probability (to 6%, 73%, 91%, and 95%, respectively) of a diagnosis of alcohol abuse or dependency. At the standard cutoff point, the Alcohol Use Disorders Identification Test detected only 51% of subjects with alcohol disorders.

CONCLUSIONS

In Latinos in primary care settings, alcohol abuse and dependence are common and the CAGE (4M) is a brief, valid, screening tool for detecting alcohol use disorders.

Management of adults recovering from alcohol or other drug problems: relapse prevention in primary care

Patients recovering from substance use disorders are commonly seen in the primary care setting, and relapse is a serious long-term problem for these patients. Extrapolating from therapeutic strategies effective in specialty addiction treatment settings, this article outlines a practical approach to relapse prevention in the primary care setting. Working within a supportive patient-physician relationship, the primary care physician can help recovering patients decrease their susceptibility to relapse, recognize and manage high-risk situations, and use available self-help, pharmacological, and specialty resources. Drawing on the therapeutic relationship and skills they already possess, primary care physicians can have an important, productive, and satisfying role in the long-term management of patients in recovery from alcohol or other drug problems.

Introduction to alcohol withdrawal

Heavy drinkers who suddenly decrease their alcohol consumption or abstain completely may experience alcohol withdrawal (AW). Signs and symptoms of AW can include, among others, mild to moderate tremors, irritability, anxiety, or agitation. The most severe manifestations of withdrawal include delirium tremens, hallucinations, and seizures. These manifestations result from alcohol-induced imbalances in the brain chemistry that cause excessive neuronal activity if the alcohol is withheld. Management of AW includes thorough assessment of the severity of the patient's symptoms and of any complicating conditions as well as treatment of the withdrawal symptoms with pharmacological and nonpharmacological approaches. Treatment can occur in both inpatient and outpatient settings. Recognition and treatment of withdrawal can represent a first step in the patient's recovery process.

Physician unawareness of serious substance abuse

PURPOSE

To describe and assess the prevalence of perceived physician unawareness of serious substance abuse.

PATIENTS AND METHODS

We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician.

RESULTS

Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22).

CONCLUSIONS

Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

The impact of alcohol-related diagnoses on pneumonia outcomes

BACKGROUND

There is controversy regarding the role of alcoholism as a prognostic factor in hospitalized patients with pneumonia.

OBJECTIVE

To assess the impact of alcohol abuse on hospitalization charges, length of hospital stay, intensive care unit use, and in-hospital mortality.

METHODS

We studied a cohort of all adults hospitalized in 1992 in Massachusetts with a principal diagnosis of pneumonia, and all Massachusetts residents hospitalized for pneumonia in 6 bordering states.

RESULTS

For the 23,198 pneumonia cases the mean total hospitalization charges were $9925, mean length of hospital stay was 9.6 days, 12% of the cases had intensive care unit stays, and 10% of the cases died during the hospitalization. In bivariate analyses, pneumonia cases with alcohol-related diagnoses had higher charges (mean, $11,232 vs $9877, P = .07), had shorter length of hospital stay (9.2 vs 9.6 days, P = .02), were more likely to experience an intensive care unit stay (19% vs 12%, P < .001), and had lower in-hospital mortality (6.0% vs 10.2%, P < .001). Multivariable analyses adjusting for comorbidity, pneumonia etiology, and demographics revealed that for pneumonia cases with alcohol-related diagnoses, risk-adjusted hospital charges were $1293 higher (adjusted mean, $11,179 vs $9888, P < .001), length of hospital stay was 0.6 days longer (10.1 vs 9.5 days, P = .001), intensive care unit use was higher (18% vs 12%; adjusted odds ratio, 1.63; 95% confidence interval, 1.33-1.98), and mortality was no different (10% with or without an alcohol-related diagnosis).

CONCLUSIONS

Having an alcohol-related diagnosis is associated with more use of intensive care, longer inpatient stays, and higher hospital charges. To understand resource utilization in cases of pneumonia, alcohol abuse is a comorbid factor that must be considered.