General practitioners' diagnostic skills and referral practices in managing patients with drug and alcohol-related health problems: implications for medical training and education programmes

The aim of this study was to determine the current practices of established general practitioners in managing patients with drug and alcohol-related problems and identify gaps in training. A random sample of general practitioners completed a survey assessing diagnostic skills and referral practices concerning alcohol and illicit drug use in general practices in February 1999, comprising 110 general practitioners registered with the Central Sydney Division of General Practice. The main outcome measures were competent skills and knowledge, willingness to treat. The majority (96%) of GPs provided clinically appropriate responses for at least one drug category, although none received this rating for all six. Most general practitioners reported that they were unwilling to treat heroin and cocaine problems themselves but expressed willingness to refer patients appropriately. More than a quarter of general practitioners were unaware of the safe drinking levels for men and women or the appropriate treatment for patients consuming above such levels. Age, years in practice, type of practice, willingness to obtain drug use histories and post-graduate training were all significantly associated with general practitioners' willingness to treat and competence in managing drug and alcohol-related problems. In this study, general practioners reported low levels of skills and referrals for treatment of illicit drug use and suboptimal skills in the management of alcohol problems. The results suggest that a more comprehensive approach to education and training is required to bring about a change in practice behaviour. [Fucito LM, Gomes BS, Murnion B, Haber PS. General practitioners' diagnostic skills and referral practices in managing patients with drug and alcohol-related health problems: implications for medical training and education programmes. Drug Alcohol Rev 2003;22:417 - 424]     

Hepatotoxicity of therapeutic short-course paracetamol in hospital inpatients: impact of ageing and frailty

Background: Paracetamol, a commonly used simple analgesic, can be fatal in overdose. Case reports suggest liver damage may occur at therapeutic doses. In older and particularly frail patients, dose reduction of therapeutic paracetamol is recommended due to concerns of an increased risk of hepatotoxicity. Aims: This study aimed to investigate the effects of ageing and frailty on the safety of paracetamol in hospital inpatients commenced on short courses of the drug. Methods: An observational cohort study of young (18–55 years, n = 19), older (≥70 years) fit (n = 24) and older frail (n = 28) hospital inpatients. Treatment group participants commenced regular paracetamol (3–4 g/day) during their hospital admission, whereas the control group was not exposed to paracetamol. In both groups, plasma alanine aminotransferase (ALT) was measured at baseline and day 5, and risk factors for raised ALT were recorded. A random serum paracetamol concentration was measured at day 5 in the treatment group. Results: No older frail treatment participants had an abnormal day 5 ALT. Odds ratios for having a day 5 ALT above the upper limit of normal (ULN) with paracetamol use, compared with unexposed controls, were 3·7 [95% confidence intervals (CI): 0·32, 41·59] for older not frail participants and 2·5 (95% CI: 0·34, 18·3) for younger participants. Decreasing frailty score independently predicted a day 5 ALT above the ULN (P < 0·05). Day 5 serum paracetamol concentrations were highest in older frail participants (P < 0·005). Conclusion: Higher paracetamol concentrations observed in frail older patients after 5 days of therapeutic paracetamol do not necessarily indicate an increased risk of hepatotoxicity.     

The assessment of frailty in older people in acute care

Aim: Develop a measure of frailty for older acute inpatients to be performed by non‐geriatricians. Method: The Reported Edmonton Frail Scale (REFS) was adapted from the Edmonton Frail Scale for use with Australian acute inpatients. With acute patients aged over 70 years admitted to an Australian teaching hospital, we validated REFS against the Geriatrician's Clinical Impression of Frailty (GCIF), measures of cognition, comorbidity and function, and assessed inter‐rater reliability. Results: REFS was moderately correlated with GCIF (n = 105, R = 0.61, P < 0.01), Mini‐Mental State Examination impairment (n = 61, R = 0.49, P < 0.001), Charlson Comorbidity Index (n = 59, R = 0.51, P < 0.001) and Katz Daily Living Scale (n = 59, R = 0.51, P < 0.001). Inter‐rater reliability of REFS administered by two researchers without medical training was excellent (kappa = 0.84, n = 31). Conclusion: In this cohort of older acute inpatients, REFS is a valid, reliable test of frailty, and may be a valuable research tool to assess the impact of frailty on prognosis and response to therapy.     

Management of opioid substitution therapy during medical intervention

Opioid substitution therapy (OST) for opioid dependence is common, and injection drug users have significant medical and psychiatric comorbidity. Many physicians will encounter OST patients in their usual practice. This article provides guidance on management of common clinical problems in this population, including OST management in hepatic failure, respiratory disease, pain management and potential drug interactions.     

Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol

BackgroundIncreases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks.ObjectivesOur pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework.MethodsWe will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists’ knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected.Project impactOur study will examine changes in pharmacists’ knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids.     

Excitation and inhibition of rat medial vestibular nucleus neurones by 5-hydroxytryptamine

The effects of 5-hydroxytryptamine (5-HT) and related compounds on the discharge rate of tonically active medial vestibular nucleus (MVN) neurones were studied in an in vitro slice preparation of the dorsal brainstem of the rat. The majority (87 of 107, 82%) of MVN neurones were excited by 5-HT. Nine cells (8%) showed a biphasic response to 5-HT, which consisted of a brief inhibition followed by excitation. Eleven cells (10%) were inhibited by 5-HT. The excitatory effects of 5-HT were mimicked by alpha-methyl-5-HT and antagonised by ketanserin and ritanserin, indicating the involvement of the 5-HT₂ subtype of 5-HT receptor. In biphasic cells, blockade of 5-HT₂ receptors by ketanserin reduced the excitatory component of the response and revealed an enhanced initial inhibition. The inhibitory effects in biphasic cells, and in cells that showed a pure inhibition in response to 5-HT, were blocked by pindobind-5-HT and mimicked by 8-hydroxy-2-(di-n-propylamino)-tetralin indicating the involvement of 5-HT1A receptors. The significance of these findings in relation to the effects of 5-HT on vestibular reflex function is discussed.