Routine Assessment of Symptoms of Substance Use Disorders in Primary Care: Prevalence and Severity of Reported Symptoms

BACKGROUND

Most patients with substance use disorders (SUDs) never receive treatment and SUDs are under-recognized in primary care (PC) where patients can be treated or linked to treatment. Asking PC patients to directly report SUD symptoms on questionnaires might help identify SUDs but to our knowledge, this approach is previously untested.

OBJECTIVE

To describe the prevalence and severity of DSM-5 SUD symptoms reported by PC patients as part of routine care.

DESIGN

Cross-sectional study using secondary data.

PARTICIPANTS

A total of 241,265 adult patients who visited one of 25 PC sites in an integrated health system in Washington state and had alcohol, cannabis, or other drug use screening documented in their EHRs (March 2015-July 2018) were included in main analyses if they had a positive screen for high-risk substance use defined as AUDIT-C score 7-12 points, or report of past-year daily cannabis use or any other drug use.

MAIN MEASURES

The main outcome was number of SUD symptoms based on Diagnostic and Statistical Manual, 5th edition (DSM-5), reported on Symptom Checklists (0-11) for alcohol or other drugs: 2-3 mild; 4-5 moderate; 6-11 severe.

RESULTS

Of screened patients, 16,776 (5.7%) reported high-risk use of alcohol (2.4%), cannabis (3.9%), and/or other drugs (1.7%), and 65.0-69.9% of those completed Symptom Checklists. Of those with high-risk alcohol use, 52.5% (95% CI 50.9-54.0%) reported ≥ 2 symptoms consistent with mild-severe alcohol use disorders. Of those reporting daily cannabis use, 29.8% (28.6-30.9%) reported ≥ 2 symptoms consistent with mild-severe SUDs. Of those reporting any other drug use, 37.5% (35.7-39.3%) reported ≥ 2 symptoms consistent with mild-severe SUDs.

CONCLUSIONS AND RELEVANCE

Many PC patients who screened positive for high-risk substance use reported symptoms consistent with DSM-5 SUDs on self-report Symptom Checklists. Use of SUD Symptom Checklists could support PC providers in making SUD diagnoses and initiating discussions of substance use.

Emergency-department diagnosis of acute myocardial infarction and ischemia: a cost analysis of two diagnostic protocols

OBJECTIVE

To assess the potential cost savings of the emergency-department (ED) diagnosis of acute myocardial infarction (AMI) and other myocardial ischemia using a nine- hour ED evaluation protocol.

METHODS

This one-year study of chest-pain evaluation unit (CPEU) patient charges was undertaken at two midwestern urban university hospital EDs. Included in the study were 447 patients presenting to the EDs with chest pain consistent with myocardial ischemia, nondiagnostic electrocardiograms (ECGs), and stable vital signs. Following initial ED evaluation, CPEU patients underwent nine hours of continuous ECG ST-segment monitoring with serum CK-MB levels determined at zero, three, six, and nine hours. Nonrandomized concurrent chest pain patients with routine ED evaluation and hospital admission without CPEU workup served as controls. At Center 1, patients with negative CPEU evaluations underwent immediate echocardiography (echo) and graded exercise testing (GXT) followed by ED release (CPEU;REL). At Center 2, CPEU patients were released from the ED for outpatient stress thallium testing (CPEU;REL). At Center 2, CPEU patients with positive workups as indicated by elevated CK-MB levels, ischemia by ST-segment monitoring, or positive echo/GXT/ stress thallium testing were admitted to the hospital for further testing. Control patients were admitted directly to the hospital to evaluate for AMI. Hospital charges for CPEU and control groups were compared.

RESULTS

(Total charges in dollars, mean +/- SD, student's t-test): [table: see text]

CONCLUSION

At both centers, hospital charges related to the acute evaluation of chest pain were significantly lower with this ED diagnostic protocol for AMI and myocardial ischemia.

Effect of helicopter transport of trauma victims on survival in an urban trauma center

This paper reports a retrospective analysis of patients with serious yet substantially survivable injuries represented by ISS scores from 20 to 39 and whether or not survival was influenced by the use of helicopters. A review of 606 of these patients with blunt trauma was performed for the period from 1983 through 1986. When the group was evaluated there were 451 patients in the ISS cohort of 20-29 and 155 in the 30-39 group. The mean age was 30.5 years and 76% were males. A total of 259 patients were transported by ambulance and 347 by helicopter. Characteristics of the two groups were similar. The mean TS was 12.7 for ambulance and 12.1 for helicopter patients. Mean GCS was 10.4 in the ambulance group and 9.6 for helicopter patients. Overall the mortality for ambulance transported patients was 13% compared to 18% for the helicopter group. We conclude that there is no survival advantage in the helicopter transported group in an urban area with a sophisticated prehospital care system. Patients of rural origin deserve further study.

Facilitated intravenous access through local application of nitroglycerin ointment

Thirty-four patients with diminutive peripheral veins requiring peripheral IV access (PIVA) in the emergency department setting were randomly assigned to one of two treatment groups. One group of patients (Group A) received application of a bland ointment to the dorsum of the hand prior to attempts at cannulation, while the other group (Group B) received application of 2% nitroglycerin ointment to the dorsum of the hand prior to cannulation attempts. Cannulation was achieved in all 34 patients in the study, but required significantly fewer attempts in Group B patients (P = .04). No side effects of the drug were observed in any patient or any staff member applying the ointments. We conclude that application of 2% nitroglycerin ointment to the dorsum of the hand is a safe, effective method of inducing local venodilation that will ensure PIVA with significantly fewer attempts at cannulation.

Efficient method for visualization and isolation of proteins resolved in polyacrylamide gels

Polyacrylamide gel electrophoresis is a popular method used to purify proteins for reconstitution experiments, amino acid composition and sequence determinations. In this report we describe methods that will be of general use in the isolation and characterization of proteins and the benefits of substituting boric acid for glycine in the electrophoresis tray buffers. We also describe how proteins resolved in a variety of gel systems (including those containing sodium dodecyl sulfate) may be rapidly visualized with 8-anilino-1-naphthalene sulfonic acid and efficiently transferred to a second gel for two-dimensional gel analysis, or isolated by electroelution for subsequent characterization.