Physicians' attitudes toward unhealthy alcohol use and self-efficacy for screening and counseling as predictors of their counseling and primary care patients' drinking outcomes

Prevalence of hazardous drinking and suspected alcohol dependence in Japanese primary care settings

OBJECTIVE

We aimed to assess the prevalence of hazardous drinking and potential alcohol dependence among Japanese primary care patients, and their readiness to change and awareness of others' concerns.

METHODS

From July to August 2023, we conducted a multi-site cross-sectional study as a screening survey for participants in a cluster randomized controlled trial. The trial included outpatients aged 20-74 from primary care clinics. Using the Alcohol Use Disorders Identification Test (AUDIT) alongside a self-administered questionnaire, we evaluated the prevalence of hazardous drinking and suspected alcohol dependence, patients' readiness to change, and their awareness of others' concerns.

RESULTS

Among the 1388 participants from 18 clinics, 22% (95% confidence interval (CI): 20% to 24%) were identified as engaging in hazardous drinking or suspected of being alcohol dependent. As the AUDIT scores increased, so did their readiness to change. However, only 22% (95%CI: 16% to 28%) of those with scores ranging from 8 to 14 reported that others, including physicians, had expressed concerns about their drinking during the past year. For those with scores of 15 or higher, the figure was 74%.

CONCLUSIONS

This study underscores the need for universal or high-risk alcohol screening and brief intervention in Japanese primary care settings. Trial registry UMIN-CTR (https://www.umin.ac.jp/ctr/) (UMIN000051388).

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Relationship Between Primary Care Providers' Perceptions of Alcohol Use Disorder And Pharmacotherapy Prescribing Rates

AIMS

Acamprosate, naltrexone and disulfiram are underprescribed for alcohol use disorder (AUD) with marked variability among primary care providers (PCPs). We aimed to identify differences between high and low prescribers of medications for AUD (MAUD) with regard to knowledge, experiences, prioritization and attitudes.

METHODS

We surveyed PCPs from a large healthcare system with at least 20 patients with AUD. Prescribing rates were obtained from the electronic health record (EHR). Survey responses were scored from strongly disagree (1) to strongly agree (5). Multiple imputation was used to generate attitude scores for 7 missing subjects. PCPs were divided into groups by the median prescribing rate and attitude. Comparisons were made using Wilcoxon rank-sum and regression.

RESULTS

Of the 182 eligible PCPs, 68 (37.4%) completed the survey. Most indicated willingness to attend an educational course (57.4%). Compared with low prescribers, high prescribers viewed the effectiveness of medications more favorably (short term 4.0 vs 3.7, P = 0.02; long term 3.5 vs 3.2, P = 0.04) and were more likely to view prescribing as part of their job (3.9 vs 3.4, P = 0.04). PCPs with positive attitudes (72.4%, CI 60.9-83.8%) had a prescribing rate of 5.0% (CI 3.5-6.5%) compared to 1.9% (CI 0.5-3.4%) among those with negative attitudes (P = 0.028). When stratified by attitude, belief in effectiveness was associated with higher prescribing among PCPs with positive attitudes but not those with negative attitudes.

CONCLUSIONS

PCPs indicated an interest in learning to prescribe MAUD. However, education alone may not be effective unless physicians have positive attitudes towards patients with AUD.

Title of the study: Practice and attitude of doctors towards patients with substance use: A study from south India

AIM

To evaluate the practice and attitude of doctors towards substance use disorders (SUD) and their management.

METHODS

Following stratified proportionate random sampling, selected doctors in the south zone of Bengaluru, India, were interviewed face-to-face using a structured questionnaire.

RESULTS

150 doctors were interviewed. In their practice, a quarter of patients (median of 27.5 (IQR: 11.45-45) use one or other form of Alcohol, Tobacco or Other Drugs of abuse (ATOD). Doctors, in general, enquire about substance use but do not actively intervene. They have mixed attitudes (both positive and negative) towards persons with SUD. A significant positive correlation was noted between the number of years of experience (post-MBBS) with practices related to "brief-intervention" (p = 0.014) and "concerned and sympathetic" attitudes (p < 0.001). However, a significant negative correlation was observed between the number of years of experience and "substance-specific management" practices (p < 0.001). Further, there was a positive correlation between "brief-interventions" practices with the attitude of being "concerned and sympathetic" (p < 0.001). A mediation analysis revealed that nearly a third of the overall effect of the number of years of experience on brief-interventions practices was mediated by a concerned and sympathetic attitude.

CONCLUSIONS

Serious efforts must be made to train doctors in the effective management of SUD. Attitudes of the doctors influence practices such as brief interventions. Programs directed towards changing the attitudes of doctors can bring changes in their practices.

Prevalence of documented alcohol and opioid use disorder diagnoses and treatments in a regional primary care practice-based research network

BACKGROUND

Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices.

METHODS

We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016).

RESULTS

Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists.

CONCLUSIONS

AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD.

Moving Away from the Tip of the Pyramid: Screening and Brief Intervention for Risky Alcohol and Opioid Use in Underserved Patients

PURPOSE

Rates of risky substance use and substance use disorders are high in primary-care practices, yet the adoption of universal screening and brief intervention (SBI) has been slow and uneven. This study aimed to describe SBI-related attitudes, practices, and perspectives regarding practice change among medical providers in a minority-majority state.

METHODS

We conducted a cross-sectional, on-line survey of a practice-based research network of medical providers serving predominantly Hispanic/Latinx and Native American patients in rural and urban settings. The main variables were clinician 1) perspectives on the need to address substance use problems in primary care, 2) current screening and intervention practices, and 3) satisfaction with and willingness to make changes to their practices.

RESULTS

Although providers endorsed alcohol and opiate misuse to be significant problems in their practices, only 25% conducted universal screening. Providers reported focusing most of their screening efforts on those with substance use dependence. In general, providers rated importance of and ability to make practice changes moderately high. There was high interest in practice coordination with the community followed by interest in a collaborative care approach.

CONCLUSIONS

Providers mainly focus efforts on the relatively few patients at the tip of the pyramid (substance use dependence) rather than on the majority of patients who comprise the middle of the pyramid (risky substance use). Practice change strategies are needed to increase universal screening with a focus on risky substance use, particularly in practices serving racial/ethnic communities.

The impact of behavioral and mental health risk assessments on goal setting in primary care

Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p < 0.001), set goals for six risks (range of differences 3.8-16.6 %, p < 0.01), and improve five risks (range of differences 5.4-13.6 %, p < 0.01). Compared to controls, intervention patients felt clinicians cared more for them and showed more interest in their concerns. Patient-centered health risk assessments improve screening and goal setting.Trial RegistrationClinicaltrials.gov identifier: NCT01825746.

Online Versus In-Person Screening, Brief Intervention, and Referral to Treatment Training in Pediatrics Residents

BACKGROUND

Pediatricians underestimate the prevalence of substance misuse among children and adolescents and often fail to screen for and intervene in practice. The American Academy of Pediatrics recommends training in Screening, Brief Intervention, and Referral to Treatment (SBIRT), but training outcomes and skill acquisition are rarely assessed.

OBJECTIVE

We compared the effects of online versus in-person SBIRT training on pediatrics residents' knowledge, attitudes, behaviors, and skills.

METHODS

Forty pediatrics residents were randomized to receive either online or in-person training. Skills were assessed by pre- and posttraining standardized patient interviews that were coded for SBIRT-adherent and -nonadherent behaviors and global skills by 2 trained coders. Thirty-two residents also completed pre- and postsurveys of their substance use knowledge, attitudes, and behaviors (KABs). Two-way repeated measures multivariate analyses of variance (MANOVAs) and analyses of variance (ANOVAs) estimates were used to assess group differences in skill acquisition and KABs.

RESULTS

Findings indicated that both groups demonstrated skill improvement from pre- to postassessment. Results indicated that both groups increased their knowledge, self-reported behaviors, confidence, and readiness with no significant between-group differences. Follow-up univariate analyses indicated that, while both groups increased their SBIRT-adherent skills, the online training group displayed more "undesirable" behaviors posttraining.

CONCLUSIONS

The current study indicates that brief training, online or in-person, can increase pediatrics residents' SBIRT skills, knowledge, self-reported behaviors, confidence, and readiness. The findings further indicate that in-person training may have incremental benefit in teaching residents what not to do.