The Short Inventory of Problems-Modified for Drug Use (SIP-DU): validity in a primary care sample

Primary care physicians can help drug-dependent patients mitigate adverse drug use consequences; instruments validated in primary care to measure these consequences would aid in this effort. This study evaluated the validity of the Short Inventory of Problems-Alcohol and Drugs modified for Drug Use (SIP-DU) among subjects recruited from a primary care clinic (n= 106). SIP-DU internal consistency was evaluated using Cronbach's alphas, convergent validity by correlating the total SIP-DU score with the DAST-10, and construct validity by analyzing the factor structure. The SIP-DU demonstrated high internal consistency (Cronbach's alpha for overall scale .95, subscales .72-.90) comparable with other SIP versions and correlated well with the DAST-10 (r= .70). Confirmatory factor analysis suggested an unacceptable fit of previously proposed factors; exploratory factor analyses suggested a single factor of drug use consequences. The SIP-DU offers primary care clinicians a valid and practical assessment tool for drug use consequences.

Young adults at risk for excess alcohol consumption are often not asked or counseled about drinking alcohol

BACKGROUND

Excessive alcohol consumption is most widespread among young adults. Practice guidelines recommend screening and physician advice, which could help address this common cause of injury and premature death.

OBJECTIVE

To assess the proportion of persons ages 18-39 who, in the past year, saw a physician and were asked about their drinking and advised what drinking levels pose health risk, and whether this differed by age or whether respondents exceeded low-risk drinking guidelines [daily (>4 drinks for men/>3 for women) or weekly (>14 for men/>7 for women)].

DESIGN

Survey of young adults selected from a national internet panel established using random digit dial telephone techniques.

PARTICIPANTS

Adults age 18-39 who ever drank alcohol, n =3,409 from the internet panel and n=612 non-panel telephone respondents.

MAIN MEASURES

Respondents were asked whether they saw a doctor in the past year; those who did see a doctor were asked whether a doctor asked about their drinking, advised about safe drinking levels, or counseled to reduce drinking.

KEY RESULTS

Of respondents, 67% saw a physician in the past year, but only 14% of those exceeding guidelines were asked and advised about risky drinking patterns. Persons 18-25 were the most likely to exceed guidelines (68% vs. 56%, p<0.001) but were least often asked about drinking (34% vs. 54%, p<0.001).

CONCLUSIONS

Despite practice guidelines, few young adults are asked and advised by physicians about excessive alcohol consumption. Physicians should routinely ask all adults about their drinking and offer advice about levels that pose health risk, particularly to young adults.

Is a patient's type of substance dependence (alcohol, drug or both) associated with the quality of primary care they receive?

BACKGROUND

Primary care clinicians' attitudes may differ based on patients' substance dependence type (alcohol, other drugs or both).

AIM

The aim of this study was to evaluate whether substance dependence type is associated with primary care quality (PCQ).

METHODS

We tested the association between substance dependence type and six PCQ scales of the Primary Care Assessment Survey (PCAS) in multivariable linear regression models. We studied alcohol- and/or drug-dependent patients followed prospectively who reported having a PCC ( n = 427) in a primary care setting.

RESULTS

We used the Composite International Diagnostic Interview-Short Form to assess substance dependence type and we used the PCAS questionnaire to measure primary care quality. Dependence type was significantly associated with PCQ for all PCAS scales except whole-person knowledge. For the significant associations, subjects with drug dependence (alone or together with alcohol) had lower observed PCAS scores compared with those with alcohol dependence only, except for preventive counselling.

CONCLUSIONS

Drug dependence was associated with worse PCQ for most domains. Understanding the reasons for these differences and addressing them may help improve the quality of primary care for patients with addictions.

Chronic disease and recent addiction treatment utilization among alcohol and drug dependent adults

BACKGROUND

Chronic medical diseases require regular and longitudinal care and self-management for effective treatment. When chronic diseases include substance use disorders, care and treatment of both the medical and addiction disorders may affect access to care and the ability to focus on both conditions. The objective of this paper is to evaluate the association between the presence of chronic medical disease and recent addiction treatment utilization among adults with substance dependence.

METHODS

Cross-sectional secondary data analysis of self-reported baseline data from alcohol and/or drug-dependent adults enrolled in a randomized clinical trial of a disease management program for substance dependence in primary care. The main independent variable was chronic medical disease status, categorized using the Katz Comorbidity Score as none, single condition of lower severity, or higher severity (multiple conditions or single higher severity condition), based on comorbidity scores determined from self-report. Asthma was also examined in secondary analyses. The primary outcome was any self-reported addiction treatment utilization (excluding detoxification) in the 3 months prior to study entry, including receipt of any addiction-focused counseling or addiction medication from any healthcare provider. Logistic regression models were adjusted for sociodemographics, type of substance dependence, recruitment site, current smoking, and recent anxiety severity.

RESULTS

Of 563 subjects, 184 (33%) reported any chronic disease (20% low severity; 13% higher severity) and 111 (20%) reported asthma; 157 (28%) reported any addiction treatment utilization in the past 3 months. In multivariate regression analyses, no significant effect was detected for chronic disease on addiction treatment utilization (adjusted odds ratio [AOR] 0.88 lower severity vs. none, 95% confidence interval (CI): 0.60, 1.28; AOR 1.29 higher severity vs. none, 95% CI: 0.89, 1.88) nor for asthma.

CONCLUSIONS

In this cohort of alcohol and drug dependent persons, there was no significant effect of chronic medical disease on recent addiction treatment utilization. Chronic disease may not hinder or facilitate connection to addiction treatment.

Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems

This is a prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the HIV Longitudinal Interrelationships of Viruses and Ethanol study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36, 95% confidence interval [95% CI] = 0.19-0.67), as did identifying sexual orientation other than heterosexual (AOR = 0.46, CI = 0.29-0.72) and having social supports that use alcohol/drugs (AOR = 0.62, CI = 0.45-0.83). Positive associations with SAT include presence of hepatitis C antibody (AOR = 3.37, CI = 2.24-5.06), physical or sexual abuse (AOR = 2.12, CI = 1.22-3.69), social supports that help with sobriety (AOR = 1.92, CI = 1.28-2.87), homelessness (AOR = 2.40, CI = 1.60-3.62), drug dependence diagnosis (AOR = 2.64, CI = 1.88-3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08-2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g., drug dependence) are associated with receipt, nonneed factors (e.g., sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.

Operating characteristics of carbohydrate-deficient transferrin (CDT) for identifying unhealthy alcohol use in adults with HIV infection

Unhealthy alcohol use (the spectrum of risky use through dependence) is common in HIV-infected persons, yet it can interfere with HIV medication adherence, may lower CD4 cell count, and can cause hepatic injury. Carbohydrate-deficient transferrin (CDT), often measured as %CDT, can detect heavy drinking but whether it does in people with HIV is not well established. We evaluated the operating characteristics of %CDT in HIV-infected adults using cross-sectional data from 300 HIV-infected adults with current or past alcohol problems. Past 30-day alcohol consumption was determined using the Timeline Followback (TLFB), a validated structured recall questionnaire, as the reference standard. Sensitivity and specificity of %CDT (at manufacturer's cut-off point of 2.6%) for detecting both "at-risk" (≥4 drinks in a day or >7 drinks per week for women, ≥5 drinks in a day or >14 per week for men) and "heavy" drinking (≥4 drinks in a day for women, ≥5 drinks in a day for men on at least seven days) were calculated. Receiver operating characteristic (ROC) curves were estimated to summarize the diagnostic ability of %CDT for distinguishing "at risk" and "heavy" levels of drinking. Exploratory analyses that stratified by gender and viral hepatitis infection were performed. Of 300 subjects, 103 reported current consumption at "at-risk" amounts, and 47 reported "heavy" amounts. For "at-risk" drinking, sensitivity of %CDT was 28% (95% confidence interval (CI) 19%, 37%), specificity 90% (95% CI 86%, 94%); area under the ROC curve (AUC) was 0.59. For "heavy" drinking, sensitivity was 36% (95% CI 22%, 50%), specificity 88% (95% CI 84%, 92%); AUC was 0.60. Sensitivity appeared lower among women and those with viral hepatitis; specificity was similar across subgroups. Among HIV-infected adults, %CDT testing yielded good specificity, but poor sensitivity for detecting "at-risk" and "heavy" alcohol consumption, limiting its clinical utility for detecting unhealthy alcohol use in this population.

Using personalized feedback to reduce alcohol use among hazardous drinking college students: the moderating effect of alcohol-related negative consequences

Web-based screening and brief interventions that include personalized feedback about their alcohol use have proven to be particularly promising for reducing hazardous drinking among university students. Despite the increasing use of these approaches, there is still relatively little known about how the content of these interventions may influence outcomes and who may benefit most from these approaches. The current study sought to address these issues by examining how individual differences in alcohol consequences influence outcomes of a laboratory-based computerized intervention.

METHODS

One-hundred and nineteen introductory psychology students who either had two episodes of heavy episodic drinking in the past month or scored ≥8 on the AUDIT participated in this randomized controlled trial for course credit. Participants were assigned to 1 of 4 conditions in this 2 Intervention (Alcohol Feedback vs. Control)×2 Assessment (Motivational Assessment vs. No Motivational Assessment) between-subjects design. Quantity of alcohol consumed per week and heavy episodic drinking one month later were the primary dependent variables.

RESULTS

Controlling for corresponding baseline alcohol measures, hierarchical linear regression analyses showed a significant interaction between intervention condition and baseline alcohol-related consequences. For those who reported more alcohol consequences at baseline, the alcohol intervention resulted in significantly less alcohol use and fewer heavy drinking episodes at follow-up, while no difference was observed between intervention conditions for those with few baseline consequences. Assessment did not moderate intervention effects.

DISCUSSION

These findings suggest that a feedback-based computerized intervention that includes normative information about alcohol use and consequences may be more effective for hazardous drinking students who are experiencing higher levels of alcohol-related consequences.

Initiation and engagement in chronic disease management care for substance dependence

BACKGROUND

Substance dependence treatment is often episodic and not well coordinated with healthcare for common comorbidities. Chronic disease/care management (CDM), longitudinal, patient-centered care delivered by multidisciplinary health professionals, may be well suited to treat substance dependence (SD).

OBJECTIVE

To examine initiation and engagement with CDM care for SD located in a primary medical setting.

METHODS

We prospectively studied substance dependent participants enrolled in a trial of CDM addiction care. Primary study outcomes, based upon Washington Circle performance measures, were 14-day initiation of CDM care and 30-day engagement with CDM care. Factors associated with these outcomes were determined using multivariable logistic regression models. We also estimated the proportion of participants who eventually attended at least two visits and four visits by the end of the study (Kaplan-Meier method).

RESULTS

Of 282 participants, approximately half of the cohort (45%, 95% Confidence Interval [CI] 39-51%) met criteria for 14-day initiation and 23% (95% CI 18-28%) for 30-day engagement with CDM care. Most participants attended two or more (81%, 95% CI 76-85%) and four or more CDM visits (62%, 95% CI 56-68%). Major depressive episode (AOR 2.60, 95% CI 1.39, 4.87) was associated with higher odds of 14-day initiation; younger age, female sex, and higher alcohol addiction severity were associated with lower odds of 30-day engagement with CDM care.

CONCLUSION

People with SD appear to be willing to initiate and engage with CDM care in a primary medical care setting. CDM care has the potential to improve the quality of care for people with addictions.

Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking

ISSUES

Although screening and brief intervention (BI) in the primary-care setting reduces unhealthy alcohol use, its efficacy among patients with dependence has not been established. This systematic review sought to determine whether evidence exists for BI efficacy among patients with alcohol dependence identified by screening in primary-care settings.

APPROACH

We included randomised controlled trials (RCTs) extracted from eight systematic reviews and electronic database searches published through September 2009. These RCTs compared outcomes among adults with unhealthy alcohol use identified by screening who received BI in a primary-care setting with those who received no intervention.

KEY FINDINGS

Sixteen RCTs, including 6839 patients, met the inclusion criteria. Of these, 14 excluded some or all persons with very heavy alcohol use or dependence; one in which 35% of 175 patients had dependence found no difference in an alcohol severity score between groups; and one in which 58% of 24 female patients had dependence showed no efficacy.

CONCLUSION AND IMPLICATIONS

Alcohol screening and BI has efficacy in primary care for patients with unhealthy alcohol use, but there is no evidence for efficacy among those with very heavy use or dependence. As alcohol screening identifies both dependent and non-dependent unhealthy use, the absence of evidence for the efficacy of BI among primary-care patients with screening-identified alcohol dependence raises questions regarding the efficiency of screening and BI, particularly in settings where dependence is common. The finding also highlights the need to develop new approaches to help such patients, particularly if screening and BI are to be disseminated widely.[Saitz R. Alcohol screening and brief intervention in primary care: Absence of evidence for efficacy in people with dependence or very heavy drinking.

Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD-related preventive care?

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

Primary care professionals from five health centres 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 assessed associations between stigmatising attitudes and readiness.

RESULTS

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 Multiple Correspondence Analysis two groups emerged: (i) 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 stigmatising attitudes); and (ii) 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 stigmatising attitudes).

DISCUSSION AND CONCLUSIONS

More stigmatising 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. [Amaral-Sabadini MB, Saitz R, Souza-Formigoni MLO. Do attitudes about unhealthy alcohol and other drug (AOD) use impact primary care professionals' readiness to implement AOD-related preventive care?

Is unhealthy substance use associated with failure to receive cancer screening and flu vaccination? A retrospective cross-sectional study

Objective To compare cancer screening and flu vaccination among persons with and without unhealthy substance use. Design The authors analysed data from 4804 women eligible for mammograms, 4414 eligible for Papanicolou (Pap) smears, 7008 persons eligible for colorectal cancer (CRC) screening and 7017 persons eligible for flu vaccination. All patients were screened for unhealthy substance use. The main outcome was completion of cancer screening and flu vaccination. Results Among the 9995 patients eligible for one or more of the preventive services of interest, 10% screened positive for unhealthy substance use. Compared with women without unhealthy substance use, women with unhealthy substance use received mammograms less frequently (75.4% vs 83.8%; p<0.0001), but Pap smears no less frequently (77.9% vs 78.1%). Persons with unhealthy substance use received CRC screening no less frequently (61.7% vs 63.4%), yet received flu vaccination less frequently (44.7% vs 50.4%; p=0.01). In multivariable analyses, women with unhealthy substance use were less likely to receive mammograms (adjusted odds ratio 0.68; 95% CI 0.52 to 0.89), and persons with unhealthy substance use were less likely to receive flu vaccination (adjusted odds ratio 0.81; 95% CI 0.67 to 0.97). Conclusions Unhealthy substance use is a risk factor for not receiving all appropriate preventive health services.

Oral health of substance-dependent individuals: impact of specific substances

Little is known about how different types of substances affect oral health. Our objective was to examine the respective effects of alcohol, stimulants, opioids, and marijuana on oral health in substance-dependent persons. Using self-reported data from 563 substance-dependent individuals, we found that most reported unsatisfactory oral health, with their most recent dental visit more than 1 year ago. In multivariable logistic regressions, none of the substance types were significantly associated with oral health status. However, opioid use was significantly related to a worse overall oral health rating compared to 1 year ago. These findings highlight the poor oral health of individuals with substance dependence and the need to address declining oral health among opioid users. General health and specialty addiction care providers should be aware of oral health problems among these patients. In addition, engagement into addiction and medical care may be facilitated by addressing oral health concerns.

Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS

BACKGROUND

Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics.

OBJECTIVE

This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems.

METHODS

Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance.

RESULTS

At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past 6 months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance.

CONCLUSIONS

Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.

Alcohol consumption patterns in HIV-infected adults with alcohol problems

OBJECTIVE

To understand patterns of alcohol consumption and baseline factors associated with favorable drinking patterns among HIV-infected patients.

METHODS

We studied drinking patterns among HIV-infected patients with current or past alcohol problems. We assessed drinking status in 6-month intervals. Based on National Institute on Alcohol Abuse and Alcoholism guidelines a favorable drinking pattern was defined as not drinking risky amounts at each assessment or decreased drinking over time. All other patterns were defined as unfavorable. Logistic regression models were used to identify baseline factors associated with a favorable pattern.

RESULTS

Among 358 subjects, 54% had a favorable drinking pattern with 44% not drinking risky amounts at every assessment, and 11% decreasing consumption over time. Of the 46% with an unfavorable pattern, 4% drank risky amounts each time, 5% increased, and 37% both decreased and increased consumption over time. Current alcohol dependence and recent marijuana use were negatively associated with a favorable pattern, while older age and female gender, and having a primary HIV risk factor of injection drug use were positively associated with a favorable pattern.

CONCLUSION

Many HIV-infected adults with alcohol problems have favorable drinking patterns over time, and alcohol consumption patterns are not necessarily constant. Identifying HIV-infected adults with a pattern of risky drinking may require repeated assessments of alcohol consumption.

Clinical factors associated with prescription drug use disorder in urban primary care patients with chronic pain

This study examined characteristics associated with prescription drug use disorder (PDUD) in primary-care patients with chronic pain from a cross-sectional survey conducted at an urban academically affiliated safety-net hospital. Participants were 18 to 60 years old, had pain for ≥ 3 months, took prescription or nonprescription analgesics, and spoke English. Measurements included the Composite International Diagnostic Interview (PDUD, other substance use disorders (SUD), Posttraumatic Stress Disorder [PTSD]); Graded Chronic Pain Scale, smoking status; family history of SUD; and time spent in jail. Of 597 patients (41% male, 61% black, mean age 46 years), 110 (18.4%) had PDUD of whom 99 (90%) had another SUD. In adjusted analyses, those with PDUD were more likely than those without any current or past SUD to report jail time (OR 5.1, 95% CI 2.8-9.3), family history of SUD (OR 3.4, 1.9-6), greater pain-related limitations (OR 3.8, 1.2-11.7), cigarette smoking (OR 3.6, 2-6.2), or to be white (OR 3.2, 1.7-6), male (OR 1.9, 1.1-3.5) or have PTSD (OR 1.9, 1.1-3.4). PDUD appears increased among those with easily identifiable characteristics. The challenge is to determine who, among those with risk factors, can avoid, with proper management, developing the increasingly common diagnosis of PDUD.

PERSPECTIVE

This article examines risk factors for prescription drug use disorder (PDUD) among a sample of primary-care patients with chronic pain at an urban, academic, safety-net hospital. The findings may help clinicians identify those most at risk for developing PDUD when developing appropriate treatment plans.

Older adults' inpatient and emergency department utilization for ambulatory-care-sensitive conditions: relationship with alcohol consumption

OBJECTIVE

This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries.

METHOD

This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission.

RESULTS

Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures.

DISCUSSION

Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Factors associated with favorable drinking outcome 12 months after hospitalization in a prospective cohort study of inpatients with unhealthy alcohol use

BACKGROUND

Prevalence of unhealthy alcohol use among medical inpatients is high.

OBJECTIVE

To characterize the course and outcomes of unhealthy alcohol use, and factors associated with these outcomes.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 287 medical inpatients with unhealthy alcohol use.

MAIN MEASURES

At baseline and 12 months later, consumption and alcohol-related consequences were assessed. The outcome of interest was a favorable drinking outcome at 12 months (abstinence or drinking "moderate" amounts without consequences). The independent variables evaluated included demographics, physical/sexual abuse, drug use, depressive symptoms, alcohol dependence, commitment to change (Taking Action), spending time with heavy-drinking friends and receipt of alcohol treatment (after hospitalization). Adjusted regression models were used to evaluate factors associated with a favorable outcome.

KEY RESULTS

Thirty-three percent had a favorable drinking outcome 1 year later. Not spending time with heavy-drinking friends [adjusted odds ratio (AOR) 2.14, 95% CI: 1.14-4.00] and receipt of alcohol treatment [AOR (95% CI): 2.16(1.20-3.87)] were associated with a favorable outcome. Compared to the first quartile (lowest level) of Taking Action, subjects in the second, third and highest quartiles had higher odds of a favorable outcome [AOR (95% CI): 3.65 (1.47, 9.02), 3.39 (1.38, 8.31) and 6.76 (2.74, 16.67)].

CONCLUSIONS

Although most medical inpatients with unhealthy alcohol use continue drinking at-risk amounts and/or have alcohol-related consequences, one third are abstinent or drink "moderate" amounts without consequences 1 year later. Not spending time with heavy-drinking friends, receipt of alcohol treatment and commitment to change are associated with this favorable outcome. This can inform efforts to address unhealthy alcohol use among patients who often do not seek specialty treatment.

The mixed evidence for brief intervention in emergency departments, trauma care centers, and inpatient hospital settings: what should we do?

BACKGROUND

This qualitative review is based on a symposia presented at the 2009 annual conference of the Research Society on Alcoholism (Baird et al., 2009; Field et al., 2009; Monti et al., 2009; Saitz et al., 2009a). The purpose is to describe the mixed evidence supporting brief interventions in the emergency department, trauma care, and in-patient medical care settings; examine potential moderators of treatment outcome in light of the mixed evidence; and identify methods to move the research and practice of brief interventions beyond their current state.

METHODS

By drawing upon existing reviews and selected individual studies, we provide examples that reflect the current complexity of research in this area and propose steps for advancing the field.

RESULTS

Emergency departments, inpatient hospital settings, and trauma care settings represent three unique contexts within which brief interventions have been tested. While the general efficacy of brief alcohol interventions in these settings has been recognized, the evidence is increasingly mixed. Recent studies investigating potential moderators of treatment outcomes suggest that a more sophisticated approach to evaluating the effectiveness of brief interventions across varying patient populations is needed to further understand its effectiveness.

CONCLUSIONS

Current dissemination efforts represent a significant advance in broadening the base of treatment for alcohol problems by providing an evidence-based intervention in health care settings and should not be curtailed. However, additional research is required to enhance treatment outcomes, refine current practice guidelines, and continue to bridge the gap between science and practice. Given the current state of research, a multisetting clinical trial is recommended to account for potential contextual differences while controlling for study design.

A single-question screening test for drug use in primary care

BACKGROUND

Drug use (illicit drug use and nonmedical use of prescription drugs) is common but underrecognized in primary care settings. We validated a single-question screening test for drug use and drug use disorders in primary care.

METHODS

Adult patients recruited from primary care waiting rooms were asked the single screening question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" A response of at least 1 time was considered positive for drug use. They were also asked the 10-item Drug Abuse Screening Test (DAST-10). The reference standard was the presence or absence of current (past year) drug use or a drug use disorder (abuse or dependence) as determined by a standardized diagnostic interview. Drug use was also determined by oral fluid testing for common drugs of abuse.

RESULTS

Of 394 eligible primary care patients, 286 (73%) completed the interview. The single screening question was 100% sensitive (95% confidence interval [CI], 90.6%-100%) and 73.5% specific (95% CI, 67.7%-78.6%) for the detection of a drug use disorder. It was less sensitive for the detection of self-reported current drug use (92.9%; 95% CI, 86.1%-96.5%) and drug use detected by oral fluid testing or self-report (81.8%; 95% CI, 72.5%-88.5%). Test characteristics were similar to those of the DAST-10 and were affected very little by participant demographic characteristics.

CONCLUSION

The single screening question accurately identified drug use in this sample of primary care patients, supporting the usefulness of this brief screen in primary care.

Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: advocacy or evidence-based practice?

The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care.

Physical health and drinking among medical inpatients with unhealthy alcohol use: a prospective study

OBJECTIVE

Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a "teachable moment" that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.

METHODS

Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n = 341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.

RESULTS

Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were nondependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03-0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13-0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.

CONCLUSIONS

Among medical inpatients with nondependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.