Increasing Primary Care Providers' Willingness to Intervene in Alcohol- and Drug-Related Problems: A Review

Alcohol Policy Issues for Indigenous People in the United States, Canada, Australia and New Zealand

This paper reviews the literature on alcohol consumption, alcohol-related problems, and national and local policy issues for indigenous people in four developed countries (United States, Canada, Australia and New Zealand). The growth of domestic self-determination and self-management policies within these countries has had an impact on the relationships between these groups and their national governments, which raises a number of questions regarding the influence of national alcohol policies on indigenous citizens. National “native” policies as well as discriminatory alcohol prohibitions have had long-standing effects, influencing indigenous responses to contemporary interventions in alcohol misuse. While national alcohol policies have had mixed impact, indigenous groups have focused on their own attempts at control, which emphasize local controls over supply; these are particularly prevalent in the far north of Canada and in Australia. Local control policies have been well evaluated in Australia, providing an evidence-based grounding for further interventions.

Alcohol, Isolation, and Access to Treatment: Family Physician Experiences of Alcohol Consumption and Access to Health Care in Rural British Columbia

OBJECTIVE

The purpose of this project was to study the experiences of physicians who treat persons with alcohol-attributed diseases in rural areas of British Columbia, Canada.

METHOD

A cross-sectional survey was distributed to primary health care physicians that had a family practice in a designated rural community using the Rural Coordination Centre of British Columbia's community isolation rating system. Data were collected through a mail and online survey sent to primary health care physicians. Purposeful sampling was used to select participants that had a primary health care practice in a designated rural community.

RESULTS

Surveys were returned by 22% of potential participants (N = 67) that had an average of 15.8 years in family practice. The majority of participants (95.4%) reported that alcohol had a negative impact on population health, and physicians expressed particular concern for alcohol consumption in relation to mental health (85.1%) and physical illness (82.1%). Most participants had referred patients out of the community for treatment; however, 76.4% reported difficulty with referrals, including long wait-lists, limited services, and issues related to transportation and leaving the community for substance use treatment.

CONCLUSION

Rural physicians showed an awareness and concern for alcohol consumption in their community, but they also reported difficulties referring patients for substance use treatment. Additional study is required to understand how to improve the continuity of care provided to persons with alcohol-related issues in rural British Columbia.

Have efforts to improve medical students' drug and alcohol knowledge, skills and attitudes worked?

A series of surveys were undertaken at one Australian medical school to examine alcohol and drug-related knowledge, skills and attitudes before and after the introduction of the National Campaign Against Drug Abuse and also before and after major alcohol and drug medical education initiatives. The surveys were conducted with 5th year medical students at the University of Sydney in 1986, 1990 and 1993 (total n = 379). Response rates of approximately 70% were achieved in each of the survey years. The three cohorts of students were similar demographically with the exception that significantly more males in 1990 and 1993 reported that English was not their first language. Very low prevalence levels for smoking were reported. By 1993, only 3% of 5th year medical students reported that they smoked. There was a significant decrease in the frequency of drinking occasions for males and females between 1986 and 1990. There was also a four-fold increase in both male and female abstainers. There was no significant difference in the amount of alcohol consumed on any drinking occasion, although there was a trend in that direction. There was a significant increase in alcohol and drug-related knowledge in the 1990 and 1993 groups, compared to the 1986 group. Skill levels were not found to change significantly across the three year groups. Students' ability to recognize NHMRC hazardous consumption levels increased substantially between 1986 and 1990. Only 4% of 1986 students considered <30 of alcohol a day to be hazardous for females compared to 47% in 1990. For men, only 8% of students considered 31-60 hazardous drinking in 1986 compared to 55% in 1990 and 61% in 1993. More recently trained students tended to express slightly more tolerant and accepting views about patients with alcohol and benzodiazepine dependence and had greater confidence in success of interventions. The present studies indicate important progress and achievements have been made. The paper discusses the further work needed to ensure that newly graduating medical practitioners are adequately equipped to deal effectively with alcohol and drug-related problems.

Effects of screening and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- post-intervention assessment

BACKGROUND

Many hazardous and harmful drinkers do not receive clinician advice to reduce their drinking. Previous studies suggest under-detection and clinician reluctance to intervene despite awareness of problem drinking (PD). The Healthy Habits Project previously reported chart review data documenting increased screening and intervention with hazardous and harmful drinkers after training clinicians and implementing routine screening. This report describes the impact of the Healthy Habits training program on clinicians' rates of identification of PD, level of certainty in identifying PD and the proportion of patients given advice to reduce alcohol use, based on self-report data using clinician exit questionnaires.

METHODS

28 residents and 10 faculty in a family medicine residency clinic completed four cycles of clinician exit interview questionnaires before and after screening and intervention training. Rates of identifying PD, level of diagnostic certainty, and frequency of advice to reduce drinking were compared across intervention status (pre vs. post). Findings were compared with rates of PD and advice to reduce drinking documented on chart review.

RESULTS

1,052 clinician exit questionnaires were collected. There were no significant differences in rates of PD identified before and after intervention (9.8% vs. 7.4%, p = .308). Faculty demonstrated greater certainty in PD diagnoses than residents (p = .028) and gave more advice to reduce drinking (p = .042) throughout the program. Faculty and residents reported higher levels of diagnostic certainty after training (p = .039 and .030, respectively). After training, residents showed greater increases than faculty in the percentage of patients given advice to reduce drinking (p = .038), and patients felt to be problem drinkers were significantly more likely to receive advice to reduce drinking by all clinicians (50% vs. 75%, p = .047). The number of patients receiving advice to reduce drinking after program implementation exceeded the number of patients felt to be problem drinkers. Recognition rates of PD were four to eight times higher than rates documented on chart review (p = .028).

CONCLUSION

This program resulted in greater clinician certainty in diagnosing PD and increases in the number of patients with PD who received advice to reduce drinking. Future programs should include booster training sessions and emphasize documentation of PD and brief intervention.

The feasibility and acceptability of introducing brief intervention for alcohol misuse in an urban aboriginal medical service

We report on the feasibility and perceived acceptability of brief motivational interviewing for hazardous alcohol use in an urban Aboriginal health service. General practitioners (GPs) were trained in brief motivational interviewing, and health workers in other aspects of the intervention. Screening was initially carried out using the AUDIT, but subsequently reduced to two simple questions. Information was obtained through a combination of participant observation by the study team, ongoing ad hoc review and feedback from staff, periodic group meetings, and one-on-one interviews with health workers and GPs. The AUDIT was felt to be intrusive and some questions were poorly understood. Brief intervention seemed to be culturally appropriate, but barriers to wider administration included lack of time and the complexity of patients' presenting health problems. As a result of the research there was an increase in general awareness and acceptability of addressing alcohol issues at the health service. This study raises a number of issues that both support and threaten the wide implementation of brief intervention in urban Aboriginal primary care settings.

Psychiatry Residents' Opinions of a Substance Abuse Rotation in a VA Hospital General Internal Medicine Unit

Written optional evaluation forms were devised to gather psychiatry residents' opinions regarding their substance use disorder rotation in a general internal medicine unit. Over a 4-year period 24 residents completed that rotation and 83% (N = 20) completed the form. Of the responding residents, 95% (N = 19) rated an above-average satisfaction with the rotation and 90% (N = 18) would recommend the rotation to other residents. All respondents 100% (N = 20) reported that the rotation met its stated training objectives. Considering the recent changes in the delivery of health care with its focus toward primary care and away from specialty care, these findings raise the possibility of incorporating the substance abuse training of psychiatry residents into the primary care setting of general internal medicine.

Factor structure of the SOCRATES in a sample of primary care patients

Motivation or readiness to change has been studied intensively in recent years in research on the use of brief interventions to change alcohol problems in the primary care setting. The purpose of this study was to investigate the factor structure and concurrent and predictive evidence for validity of the short Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), a 19-item self-report instrument developed to measure readiness to change alcohol problems in individuals presenting for specialized alcohol treatment. The participants were 210 men and 91 women who were identified as "at-risk" drinkers in 13 community primary care clinics. These individuals completed the SOCRATES and a number of other assessments as part of a preintervention evaluation. A principal components analysis of the SOCRATES data revealed a two-factor structure: a confirmatory factor analysis showed that this structure was a better fit to the data than the three-factor structure that Miller and Tonigan (1996) identified for the SOCRATES. The two factors (9 and 6 items, respectively), seemed to measure perceived degree of severity of an existing alcohol problem (called "Amrec" because it consisted of Miller and Tonigan's ambivalence and recognition items) and taking action to change or to maintain changes in one that exists (called "Taking Steps"). Predictions of significant and nonsignificant correlations between the two derived factors and other baseline variables (alcohol consumption, related problems and symptoms, and demographic factors) generally were confirmed. In addition, baseline Amrec scores were related in predicted directions to 6-month alcohol consumption and related problems data, but the magnitude of these relationships were reduced when other variables that correlated with Amrec or when the 6-month data were taken into account. In general, Taking Steps showed little or no relationship to the 6-month data. The results are compared to previous work with the SOCRATES and suggestions for future research are discussed.

Teaching medical students alcohol intervention skills: results of a controlled trial

OBJECTIVE

To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills.

DESIGN

In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients.

SETTING

Faculty of Medicine and Health Sciences of the University of Newcastle, Australia.

SUBJECTS

Final-year medical students.

RESULTS

Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods.

CONCLUSIONS

Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.

Brief Intervention in Hazardous Drinking: An Important Adjunct to Medical School ATOD Curriculum

Most medical school alcohol, tobacco and other drug (ATOD) curricula emphasize the diagnosis and treatment of alcohol abuse and dependence, even though a significant amount of alcohol-related morbidity and mortality is associated with the hazardous use of alcohol. An increased emphasis on screening for hazardous drinking and the use of early intervention has been shown to be effective in reducing heavy drinking in the primary care setting. This paper describes a family medicine clerkship seminar on clinical preventive medicine that focuses on tobacco and alcohol use. Results indicate that students learn that brief intervention counseling can influence patient behavior and plan to continue to use it in future patient encounters. However, the low number of students electing to intervene in hazardous drinking suggests that more curricular time is needed to overcome student resistance to addressing the alcohol use patterns of their patients.