Swimming upstream: how and why an alcohol misuse screening and intervention service using the AUDIT can have limited impact in primary care

An alcohol-screening project using the AUDIT questionnaire (World Health Organisation 1992a) was undertaken in several primary healthcare centres in the eastern sector of Cardiff in 1997/1998. The aim of the project was three-fold: &#148 to raise awareness of problematic drinking in primary healthcare attenders &#148 to encourage GPs to perform brief alcohol education with their patients in addition to laboratory screening &#148 to offer primary care attenders identified as 'alcohol problem very likely' (AUDIT score greater than eight) a brief motivational interviewing counselling session with the nurse co-ordinating the project. This paper describes the process of implementing the screening and counselling service. Methods of AUDIT questionnaire distribution, reasons given for screening and cooperation of primary healthcare staff each have an impact on results. When administered anonymously in a pilot project, the AUDIT questionnaire identified very high rates of problematic drinking. Fifty-eight per cent of all those screening positive had some recorded intervention by their GP, but the majority were highly resistant to further counselling. The views of the primary healthcare staff involved in the project and those patients who attended for counselling are discussed.     

Use of Drugs,Tobacco, Alcohol and Illicit Substances in a French Student Population

ObjectiveTo investigate perceived health status and prevalence of drug use, tobacco smoking, consumption of alcohol and illicit substances in a student population.MethodsData were obtained from an anonymous questionnaire distributed to first-year students of the Toulouse University. Collected data concerned socio-demographic characteristics, perceived health status, and consumption of tobacco, alcohol, illicit substances and drugs.ResultsFifty seven percent of the 3 561 responders declared to have taken at least one drug during the week preceding the questionnaire. Most commonly Anatomical, Therapeutic and Chemical (ATC) classes used were genito-urinary system and sex hormones (29.6%), nervous system (16.4%) and alimentary tract and metabolism (14.1%). Twenty three percent of students were smokers. Differences according to health perception were found for tobacco and cannabis consumption. Anxiety was significantly more prevalent among students reporting that they did not consume alcohol (p < 0.05)ConclusionMore than half of students use drugs. Other consumptions (tobacco, alcohol and illicit substances) are related with perceived health status.     

Detection of alcohol misusing patients in accident and emergency departments: the Paddington alcohol test (PAT)

OBJECTIVE: To develop an effective but practical screening questionnaire for use by accident and emergency (A&E) staff to detect alcohol misuse early on in its natural history, without unreasonably prolonging patient waiting times; and to integrate an alcohol health worker (AHW) into A&E to provide counselling for referred patients. METHODS: Two pilot studies for adult patients were undertaken to develop the 1 min Paddington alcohol test (PAT), which has only three compulsory questions for detecting alcohol misuse: two cover peak consumption and frequency of possible binge drinking, and the third asks whether in the patients' view their attendance at A&E was alcohol related. The use of the PAT was validated in "appropriate" adult patients over a one year period. Patients found to be positive were invited to attend the A&E review clinic for counselling by the AHW. RESULTS: The development of the PAT resulted in a referral rate of one patient per 158 A&E adult attenders, facilitating a counselling rate of one patient per 263 A&E adult attenders by the AHW. This counselling rate is a 10-fold increase on the rate of one patient per 2610 adult attenders found in a study undertaken during 1988-90. CONCLUSIONS: The use of the PAT is one practical method for A&E staff to detect the alcohol misusing patient for referral to a departmental alcohol health worker.     

Effectiveness of the rehabilitation for addicted prisoners trust (RAPt) programme

Alcohol and drug use are major health concerns on university and college campuses. It has previously been found that parental rearing patterns are related to the frequency of substance use. Further, perceptions that drug use is dangerous have been found to be related to less substance use. However, little research has directly examined the impact of parental rearing patterns on substance use by university students, and no research has examined the effects of both risk perception and parenting on substance use. Therefore, this research surveyed the frequency and extent of alcohol, cigarette and illicit drug use by students (N = 336) at a Canadian university residence, classes and health services and examined the relationship between the results with parental bonding and risk perception. It was found that “affectionless control” parenting patterns in the mother, but not the father, were related to greater drinking and drinking problems and to the use of illicit substances. Lower perceptions of risk were related to greater use of alcohol, cigarettes, cannabis and other illicit substances. Unexpectedly, there was little relationship between parental rearing and risk perceptions, suggesting that there are other avenues whereby parenting leads to greater alcohol use. Implications are discussed.     

Trends in drinking,smoking and illicit drug use among 15‐ and 16‐year‐olds in the UK (1995–2003)

This paper describes the results of drinking, smoking and illicit drug use among a representative sample of 2,032 UK school students aged 15 and 16 years in a cross‐sectional, single‐phase survey based on a stratified cluster sample of 77 UK secondary schools between March and July 2003. These findings are compared with those of two earlier surveys conducted in 1995 and 1999. Pupils completed a 380‐item standardized questionnaire under examination conditions. Over 90% had consumed alcohol at some time and 75% had experienced being drunk; almost 30% had smoked cigarettes in the past 30 days and almost 40% had tried illicit drugs at some time, mainly cannabis. Comparison with two previous surveys suggests that “binge” drinking among girls had risen and illicit drug use had fallen between 1995 and 1999 and that there was no further change in 2003. For boys, there was a significant drop in the variable “cigarette smoking in the past 30 days” between 1999 and 2003. There were no statistically significant changes in frequency of alcohol consumption and experience of intoxication between 1995 and 2003. The statistically significant increase in binge drinking among girls contrasts with the stability of the other variables considered over the 8 years under consideration. Heavy or “binge” drinking and illicit drug use amongst teenagers are clearly still matters for real concern. The increase in risky drinking among girls requires special attention. Even so, the continued tobacco use of some teenagers remains the major risk to health. It is concluded that past strategies to curb potentially problematic use of alcohol, tobacco and illicit drugs have met with only limited success. Health promotion is clearly not enough to reduce the risks associated with legal and illicit drugs by young people. Innovative “harm minimization” measures should be adopted and evaluated.     

Helping methadone patients who drink excessively to drink less: short-term outcomes of a pilot motivational intervention

Opiate addicts receiving methadone treatment who drink alcohol excessively tend not to reduce their drinking, which may imperil continued treatment as well as increasing health risks. The first study asked 136 methadone patients in a community treatment service about their alcohol consumption and requested the 116 who reported drinking during the previous year to complete the AUDIT. Thirty-two (24% of all) reported drinking above 'safe limits' (< 21 units per week for men, < 14 for women) during the previous week: 49 (36% of all) had AUDIT scores of 8 or more. A significant minority are potentially at risk. The second study explored the possibility of helping such patients to drink less by offering nine sessions of focussed help (involving the Drinkers' Check-up) using motivational interviewing techniques. Of the 39 patients referred, 22 attended for assessment, were identified as having a drinking problem, and were offered the structured intervention. Fourteen took up the offer, of whom 11 had good short-term outcomes (10 stopped drinking, and one reduced weekly consumption from 90 units to 30); three did not reduce their consumption. These short-term results encourage the development of ways of helping this group: the experience of providing the service suggests ways of doing this.     

Nonfatal overdose from alcohol and/or drugs among a sample of recreational drug users

Abstract

The purpose of this study was to examine nonfatal overdose events experienced among a sample of recreational drug users. We sought to determine predictors of nonfatal overdose from alcohol and/or drugs among a sample of recreational drug users. In addition, we examined the substance(s) used at the last overdose event. Methods: Participants were 637 recreational illicit drug users (had used illicit drugs other than marijuana, in a club or party setting), aged 19 or older, from Victoria or Vancouver, British Columbia, Canada. Data were obtained in structured interviews conducted from 2008 to 2012 as part of the Canadian Recreation Drug Use Survey (CRDUS). Results: In the 12 months prior to interview, 19.3% (n?=?123) of the participants had experienced an overdose. In multivariate analysis, younger age, unstable housing, and usually consuming eight or more drinks containing alcohol, when drinking, significantly increased overdose risk. In addition, polysubstance use was reported by 67.5% (n?=?83) participants at their last overdose event. Conclusions: Intervention and prevention measures seeking to reduce overdoses among recreational drug users should not only address illicit drug use but also alcohol and polysubstance use. In addition, measures may target those who usually consume high amounts of alcohol when drinking are younger and who experience housing instability.     

Associations of age at cannabis first use and later substance abuse with mental health and depression in young men

Purpose: This study aimed to determine if the associations between age at cannabis first use and mental health and depression persist after controlling for the misuse of cannabis, other illicit drugs, alcohol and cigarettes.

Methods: Baseline data from an ongoing cohort study on substance use risk factors were used (N?=?5521). The association between age at cannabis first use and the frequency of cannabis use was assessed using a Cox proportional hazard model. Associations with other illicit drug use, alcohol dependence, nicotine dependence, mental health and depression were tested using linear regressions and logistic regressions.

Results: Participants using cannabis “almost every day” were on an average two years younger at cannabis first use than those using cannabis “once a month or less”. Age at cannabis first use was also associated with other illicit drug use, alcohol dependence and nicotine dependence. Associations with mental health and depression were substantially attenuated after adjustment for the misuse of cannabis and other substances.

Conclusions: These findings show that early cannabis onset is associated with later impairments in mental health and depression; however, these are largely explained by later substance abuse. Effective preventive measures are needed to delay cannabis onset and to avoid the progression from cannabis to using other drugs.     

Prevalence and characteristics of patients with risky alcohol consumption presenting to emergency departments in rural Australia

Objective: This study measures the prevalence of problematic alcohol consumption in patients of EDs in rural areas of Australia, relative to the general population in the same rural communities. It also identifies the characteristics associated with risky drinking in rural ED patients. Methods: Surveys containing the Alcohol Use Disorders Identification Test (AUDIT) and questions corresponding to the 2001 Australian Alcohol Guidelines were completed by 1056 patients presenting to five EDs in rural areas of New South Wales, and 756 residents of the same five communities. Results: Relative to the general community, ED patients were statistically significantly more likely to engage in risky alcohol consumption according to the AUDIT (39% vs 20%), alcohol consumption posing a high risk of short‐term harm (26% vs 18%) and alcohol consumption posing a high risk of long‐term harm (7% vs 3%). Although being aged under 40 years of age, being unmarried, not completing school and being assigned less urgent triage categories were associated with risky alcohol use among ED patients, rates of risky consumption were high across all patient subgroups. Conclusions: Risky drinking, across a number of measures, is overrepresented in patients of rural Australian EDs relative to the general community, and this type of consumption is not limited to certain subgroups of patients. There is a need for interventions that address both heavy single occasion drinking and excessive regular consumption in patients of rural Australian EDs, with universal interventions recommended rather than targeted programmes.     

Alcohol use among young adults presenting to the emergency department

Objectives: To determine the prevalence of young ED patients at risk from hazardous alcohol consumption, to identify high‐risk patient subgroups and evaluate the feasibility of use of the Alcohol Use Disorders Identification Test (AUDIT) in this setting. Methods: We undertook a cross‐sectional survey of 336 ED patients aged 18–30 years, inclusive. All were breathalysed prior to self‐administering the AUDIT. A ‘positive’ AUDIT score (≥8) defined hazardous alcohol consumption. AUDIT scores were correlated with sex and trauma diagnosis. Results: One hundred and thirty‐one (39.0%, 95% confidence interval [CI] 33.8–44.5) patients were classified as AUDIT‐positive. Men were significantly more likely to be AUDIT‐positive (49%vs 23%, P < 0.001) and had significantly higher total AUDIT scores (P < 0.001) than women. Trauma patients were significantly more likely to be AUDIT‐positive (P < 0.001) and had significantly higher AUDIT scores than non‐trauma patients (P < 0.001). Of the six patients who recorded a positive breath alcohol reading, all were AUDIT‐positive. One hundred (76.3%, 95% CI 68.0–83.1) AUDIT‐positive patients did not report others being concerned about their drinking or had not been given advice to cut down. Conclusion: It is feasible to use the AUDIT screening tool in the ED to identify those at risk from hazardous drinking. In our ED there is a high prevalence of hazardous alcohol consumption in young adult patients, many of whom have not previously received advice to cut down on their drinking.     

PS1-01: Alcohol and Drug Use Among Chronic Opioid Therapy Patients

Background/Aims Opioid misuse and abuse is a significant public health problem, and there is a need to better identify at-risk individuals. Study aims were to examine patient characteristics associated with alcohol and other drug (AOD) use and aberrant drug related behaviors in chronic opioid therapy (COT) patients. Methods We conducted a telephone survey of a random sample of 972 COT patients in an integrated health care delivery system in 2009. Measures included weekly alcohol use and any illicit drug use in the last three months, and a composite measure of alcohol-only use, drug-only use, both alcohol and drug use, and tobacco only use. We conducted weighted multivariate logistic regressions models of AOD use and of aberrant drug-related behavior. Results Fourteen percent were weekly alcohol users (134/972), 16% used illicit drugs (157/972), 9% (83/972) used both alcohol and drugs, 8% used only drugs (74/972), 34% (334/491) used only alcohol, and 50% (481/972) did not use any substances. Multivariate models indicated illicit drug use was associated with a higher likelihood for weekly alcohol use, while being female, a higher daily opioid dose, and greater pain severity was associate with a lower likelihood of weekly alcohol use. Tobacco use, weekly alcohol use, depression symptoms, being male, and middle age was associated with a higher likelihood of illicit drug use. For aberrant drug related behaviors, drug-only use and both alcohol and drug use (compared to no AOD use) were associated with a higher likelihood of receiving opioids from friends or family in the last year, as were postive depressive symptoms and younger age. Both AOD use and depression symptoms were associated with a higher likelihood of giving opioids to others, while a high daily dose was associated with a lower likelihood of giving opioids to others, compared to the lowest dosage. Polysubstance use gender, and depression were risk factors in this sample. Post hoc analyses of primary care utilization indicated that those with high dosage opioids were more likely to have a certain threshold of primary care visits in the last year, suggesting there is an opportunity to manage these high risk patients.     

A protocol to improve analgesia use in the accident and emergency department.

OBJECTIVE--To assess the use of analgesia in an accident and emergency (A&E) department and identify shortcomings. SETTING--University teaching hospital. METHODS--An audit of patients referred from the A&E department to orthopaedic fracture clinic (n = 100) or for orthopaedic admission (n = 100) was carried out to document analgesia use. An analgesia protocol was introduced and analgesia use was reassessed on the same numbers of patients. RESULTS--Prescribing of analgesia was initially poor: 91% of fracture clinic referrals and 39% of admissions received no analgesia while in the A&E department; when given, it was often by inappropriate routes. Introduction of an analgesia protocol significantly improved analgesia use: fracture clinic referrals receiving unsatisfactory analgesia were reduced from 91% to 69% (P < 0.001). There was a marked increase in the use of intravenous analgesia, from 9% to 37% (P < 0.001). CONCLUSIONS--Large numbers of patients still receive no analgesia while in the A&E department. This seems to be a common problem requiring intervention at a national level. The absence of a coordinated approach to improving analgesia provision for acute trauma in the United Kingdom should be addressed urgently.     

Licit and illicit drug use and social change among Bedouin Arabs in southern Israel

This study examines the levels of licit and illicit drug use among the urbanized and non-urbanized Negev Bedouin Arabs in Israel. In addition, issues of social relationships, environment and change, and socio-cultural values toward substance use were explored. The sample included 312 respondents, 150 from the urbanized settlements and 162 from the non-urbanized settlements. The results revealed that 64% of Bedouin reported using cigarettes, 90% of whom reported smoking daily. Cigarette use was significantly higher among non-urbanized (74%) than urbanized (55%) Bedouin. Thirty-one per cent of urbanized Bedouin and 30% of non-urbanized Bedouin reported ever using alcohol. Fifteen per cent of urban and non-urban Bedouin reported ever using illegal drugs, mainly cannabis. The majority of Bedouin substance users were under the age of 35. This strongly suggests that substance use, and in particular alcohol and drug use, represents a new phenomenon in this society. The Bedouin are in a transitional phase, which exposes them extensively to new and conflicting sets of social values, norms and behavioural patterns.     

Readiness to change alcohol and illicit drug use among a sample of emergency department patients

Objective: This study sought to (1) provide estimates of alcohol and illicit drug use, alone and in combination, among a sample of adult emergency department patients and (2) examine readiness to change.

Methods: Consecutive emergency department patients ≥18 years of age from a large regional hospital in Camden, NJ, were enrolled from May to December 2005. Patients provided information on alcohol and illicit drug use, as well as on interest in quitting each of these substance classes.

Results: Of the 1549 subjects surveyed, 98 (6%) indicated weekly use of both alcohol and illicit drugs, and 58 (4%) indicated problems associated with use of both substance classes. Problem users of illicit drugs felt that quitting drugs was more important, that they were more ready and that they were more confident in quitting than problem users of alcohol.

Conclusion: Problem use of multiple substances was relatively common in this emergency department sample. A substantial proportion of problem users of both substance classes were highly motivated to quit the use of one, but not the other, substance class. Further longitudinal and clinical trial research is needed to study the implications of multiple substance use, motivation to change and cessation.     

Management of alcohol misuse in Scotland: the role of A&E nurses.

Despite national targets to reduce excessive drinking in Scotland, rates have increased dramatically since the mid-eighties. The role of Accident and Emergency (A&E) departments in the management of alcohol misuse is much debated. This postal survey was conducted with senior medical and nursing staff in A&E departments and minor injury units throughout Scotland to examine the prevalence of alcohol-related attendances and staff's attitudes towards identifying and responding to alcohol-related attendances. A 57% response rate was achieved, representing 87% of all A&E institutions in Scotland (n = 84). The results reveal an estimated 1 in 7 attendances in A&E in Scotland are alcohol-related, and 1 in 5 of these result in admission. However, over two-fifths of departments do not routinely screen for, or keep records of, patients who attend with alcohol problems. Intervention is normally limited to a brief dialogue and referral to the patient's GP. Despite considerable barriers, A&E nursing staff express a willingness to assume a preventive role, but acknowledge lack of appropriate training and sources of support. It is concluded that there is scope for developing identification and brief intervention services within A&E. However, such developments are dependent upon alcohol issues assuming a higher priority among senior A&E staff.     

Going out drinking: the centrality of heavy alcohol use in English adolescents’ leisure time and poly-substance-taking repertoires

Using data from a large-scale longitudinal study, this paper highlights the development and centrality of regular, heavy drinking in the leisure priorities of a cohort of English adolescents (13-18 years). A core cohort (n = 815) with complete survey data across the study is used alongside qualitative interview data. Weekly drinking increased incrementally from 22.9% at 13 years to 73.7% at 18 years. A third of the cohort at 18 years, based on past 7-day consumption, were drinking over twice ‘safe’ limits. Heavy drinkers were far more likely to be smokers and two-thirds (67.5%) had also used an illicit drug in the past year. The combining of alcohol and illicit drugs was widespread on ‘nights out’. Drug use was facilitated by going out drinking in respect of set, setting, access and intoxicated decision making. The ‘going out’ sub-sample in this cohort who drank heavily/used drugs have displayed few psychosocial risk markers. Most share the protective factors of being in education, employment or training and coming from conventional families. Practically significant ‘risks’ in the going-out group were situational and consequential, being related to their propensity to prioritise going out at weekends to get intoxicated as part of their ‘time out’. Public health/harm reduction initiatives are recommended to reduce negative outcomes.     

Substance misuse, anxiety and depression and urgency of presentation to a public emergency department in Australia

Objectives: To establish the prevalence and comorbidity of substance‐related problems and anxiety and depression, among ED presentations, and to compare the prevalence of these conditions among more and less urgent presentations. Design and setting: Cross‐sectional survey of ED presentations over a 14 day period (24 h/day) at the Gold Coast Hospital Emergency Department in south‐east Queensland, Australia, in October 2002. Measures: Usual level of alcohol consumption (Alcohol Use Disorders Identification Test), acute alcohol and illicit drug use (during 24 h prior to interview), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and triage category (Australasian Triage Scale). Results: Thirty‐one per cent of the sample reported usually consuming alcohol at a hazardous or harmful level. Twenty per cent of participants reported clinically significant levels of anxiety and/or depression, which were in turn significantly associated with hazardous and harmful levels of alcohol use. Hazardous/harmful alcohol consumption was over‐represented among less urgent ED presentations, whereas anxiety and depression were more prevalent among more urgent ED presentations. Conclusions: Emergency departments in Australia are appropriate settings for the detection of both substance use and mental health problems in the wider community. The prevalence of these problems in ED settings is high and there is a need for the development of systematic screening and referral processes. The evidence of a link between urgency of presentation and these problems needs to be further explored.