A comprehensive package of support to facilitate the treatment of problem drug users in primary care: an evaluation of the training component

Since the early 1980s, government policy documents and specialist reports have encouraged the involvement of general practitioners (GPs) in the treatment of problem drug users. In spite of such policy initiatives, their involvement has been patchy and slow. In response to this apparent reluctance, the London Boroughs of Brent and Harrow established the substance misuse management project (SMP) to support and train GPs in the management of substance misuse. The SMP is a GP-led project that provides ongoing support, shared-care protocol, primary care team training, treatment audits and financial reimbursements. In 1996, the SMP worked with GPs who were not currently involved in treating problem drug users, and those who were providing only minimal interventions. This paper evaluates the training and support given to these GPs and examines changes in their practice. A pre- and post-test survey was undertaken of GP knowledge, attitudes and levels of activity. A structured questionnaire was administered to all GPs before training (n=40) and re-administered between 6 and 9 months following training. SMP audit data were also reviewed to validate any reported changes in practice. All GPs initially reported insufficient knowledge to manage problem drug users. One-fifth were unaware they could prescribe methadone, and nearly half believed drug problems should be treated by specialist services. Post-training, the GPs had increased their levels of treatment activity and reported greater confidence and willingness to treat. This study demonstrates the potential to involve GPs in the treatment of problem drug users. The training was part of a package that included ongoing support sessions, team training, audits of treatment and financial reimbursements. It is proposed that, whilst training is a necessary condition, a more comprehensive package of support is needed to facilitate the treatment of problem drug users in primary care.     

Training primary health care professionals to prvide Buprenorphine and LAAM treatment

This paper describes the development and implementation of training programs for primary care medical practitioners and pharmacists in the delivery of buprenorphine and LAAM treatment in the management of opiate dependence. Separate training programs were developed for each medication. Each training package included learning objectives, training materials, and assessment instruments. Findings of the evaluation of these initiatives and the subsequent Australian postregistration training program for buprenorphine are described.     

Utility and value of a medicines information service provided by pharmacists: a survey of health professionals

Objectives Many health professionals lack the time and skills to search for and appraise information on medicines. A solution might be to use others skilled in evidence appraisal, who make recommendations or provide information tailored to patients' needs. The objectives of this study were to assess how advice provided to health professionals by the northwest of England regional medicines information centre is used, whether it is useful for patient care and to measure satisfaction with the service. Methods A questionnaire was designed and sent to health professionals who contacted the centre between September 2008 and March 2009. Enquirers contacting the centre more than once were sent a questionnaire only in response to their first enquiry during the study period. Non‐responders were sent a reminder. Key findings Questionnaires were sent to 672 enquirers; 68% were returned. Nearly all respondents used the advice provided. Of the 430 respondents who provided data on how they used the information, 81% used it to manage a current patient and 29% to plan the care of future patients; nearly all considered it useful. Where data were given (n = 366), half used it to check if current or proposed management was appropriate, 45% to make changes to therapy and 35% to advise another health professional. In addition to patient care, one‐quarter (n = 105/430) of respondents used the information for continuing professional development and 16% (n = 69/430) for training or teaching. Conclusions Health professionals value the enquiry‐answering service and use the advice provided for patient care, continuing professional development and educating patients and other health professionals. The service is responsive, supporting the care of patients needing immediate and future management.     

Injection drug use among female sex workers in Iran: Findings from a nationwide bio-behavioural survey

BackgroundGlobally, one in three women who inject drugs is involved in sex work which increases their vulnerability to sexually transmitted infections including HIV. This study was conducted to improve our understanding of injection drug use practices among Iranian female sex workers (FSWs) and shed light on the high-risk profile of FSWs who inject drugs (FSW-IDUs).MethodsThis survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 13 cities in Iran. Data were collected through face-to-face interviews and lifetime injection drug use was assessed through the responses to the question “Have you ever injected any illicit drugs?”. Independent variables included a range of socio-demographic and risk characteristics. Logistic regression models were applied to investigate the correlates of lifetime history of injection drug use.ResultsMedian (Q1, Q3) age of the participants was 30 (25, 37) and a total of 127 (14.6%, 95% confidence interval (CI): 12.3–17.1) had ever injected drugs. In the multivariable logistic regression model, older age (adjusted odds ratio (AOR) = AOR_{25–34 vs. <18} = 3.37, 95% CI: 1.64, 7.70; AOR_{≥35 vs. <18} = 2.80, 95% CI: 1.11, 7.10), longer duration (>5 years) of involvement in sex work (AOR = 1.06, 95% CI: 1.02, 1.10), and history of drinking alcohol (AOR = 4.42, 95% CI: 2.67, 7.32) were positively associated with lifetime history of drug injection and younger age at sex work debut (AOR = 0.52, 95% CI: 0.28, 0.96) was negatively associated with lifetime history of illicit drug injection among FSWs.ConclusionThe prevalence of injection drug use among FSWs in Iran is concerning. Given the potential of this sub-population in bridging HIV into the general population, gender-sensitive and peer-led harm reduction programs should be further scaled up to meet the special needs of this vulnerable population.     

Sexual orientation and substance abuse treatment utilization in the United States: Results from a national survey

This study examined substance abuse treatment utilization across three dimensions of sexual orientation (identity, attraction, and behavior) in a large national sample of adults in the United States. Prevalence estimates were based on data collected from the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions. The sample consisted of 34,653 adults 20 years and older, and represented a population that was 52% women, 71% White, 12% Hispanic, 11% African American, 4% Asian, and 2% other race/ethnicities. An estimated 2% of the target population self-identified as lesbian, gay or bisexual; 4% reported same-sex sexual behavior, and 6% reported same-sex sexual attraction. Sexual minorities, especially women, had a greater likelihood of lifetime substance use disorders and earlier age of drinking onset. The majority of respondents with substance use disorders were untreated and lifetime substance abuse treatment utilization differed based on sexual orientation. Sexual minorities were found to have more extensive family histories of substance abuse problems. The findings indicate the underutilization of substance abuse treatment among all adults, and highlight some important factors to consider when working with sexual minorities.     

2015-2017年上海市8家基层医疗机构口服降糖药物利用评价

目的 通过调查2015—2017年上海市崇明区8家基层医疗机构(以下简称“崇明区8家医院”)口服降糖药的应用现状,评价利用情况及用药趋势,为临床合理用药提供参考。方法 采用金额排序分析和用药频度分析方法,对崇明区8家医院2015—2017年口服降糖药的用药金额、用药频度(DDDs)和限定日费用(DDC)等进行回顾性统计分析。结果 2015—2017年崇明区8家医院口服降糖药的使用总金额和DDDs总体呈逐年增长趋势,用药金额排序列前3位的分别为格列美脲、阿卡波糖、吡格列酮;DDDs排序列前3位的分别为格列美脲、二甲双胍、吡格列酮。2015—2016年DDC排序列前3位的依次为阿卡波糖、瑞格列奈、那格列奈,2017年DDC排序列前3位的是阿卡波糖、沙格列汀和西格列汀,而二甲双胍、格列美脲3年的DDC均较低;用药金额排序与DDDs排序的比值(B/A)在0.33~2.50之间。结论 格列美脲、二甲双胍及吡格列酮是崇明区8家医院2015—2017年最常用的品种,口服降糖药的应用基本合理,临床更倾向于选择每日服用一次的长效口服降糖药。     

Perceptions of behavioral health care among veterans with substance use disorders: Results from a national evaluation of mental health services in the Veterans Health Administration

Understanding patients' perceptions of care is essential for health care systems. We examined predictors of perceptions of behavioral health care (satisfaction with care, helpfulness of care, and perceived improvement) among veterans with substance use disorders (SUD; n = 1,581) who participated in a phone survey as part of a national evaluation of mental health services in the U.S. Veterans Health Administration. In multivariate analyses, SUD specialty care utilization and higher mental health functioning were associated positively with all perceptions of care, and comorbid schizophrenia, bipolar, and PTSD were associated positively with multiple perceptions of care. Perceived helpfulness of care was associated with receipt of SUD specialty care in the prior 12 months (adjusted OR = 1.77, p < .001). Controlling for patient characteristics, satisfaction with care exhibited strong associations with perceptions of staff as supportive and empathic, whereas perceived improvement was strongly linked to the perception that staff helped patients develop goals beyond symptom management. Survey responses that account for variation in SUD patients' perceptions of care could inform and guide quality improvement efforts with this population.     

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

Objectives: Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

Methods: We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

Expected results: The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients’ quality of life, functioning and participation.

Conclusions: The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.     

The 5-Step family intervention in primary care: I. Strengths and limitations according to family members

Background: Family members affected by a close relative's substance misuse constitute a large but neglected, high-risk group. Interventions for that group are now being developed and tested in trials. More use should be made of qualitative methods to study process in such interventions.

Design: Semi-structured interviews with family members 12 weeks after assignment to a full or brief 5-Step intervention. Both involved a primary care professional giving a self-help manual, and the full version also involved up to five sessions of a psychosocial intervention.

Participants: 143 patients of GPs, health visitors and practice nurses in general practices in two areas of England. Patients were the family members of close relatives with drinking or other drug problems.

Analysis: Framework analysis and grounded theory analysis of post-interview reports.

Results: There was strong support for a form of intervention that involved face-to-face discussion with a primary care professional, and those who received the full intervention were appreciative of being able to talk to a professional who had time to listen and who appeared interested, understanding and caring. The self-help manual itself was reported to contain active ingredients for change, and a number of family members described transformations in their ways of coping with the problem whether they received the full or brief form of intervention. A common constellation of changes included increased consciousness of the nature and extent of the relative's drinking or drug use and its family effects, an acknowledgement of the family member's own needs and rights, a strengthening of resolve to assert plans and expectations, and a calming effect with reduction in stress symptoms. Many participants were unable to describe changes, however, and the following principal limitations of the intervention were described: prior familiarity with the material, perception that the intervention did not go far enough, belief that it was incapable of effecting change for the substance misusing relative, and a perception that sufficient professional expertise or sympathy was not always available in primary care.

Conclusions: Findings suggest that the 5-Step family intervention has positive potential in the primary care setting, but has limitations and may need strengthening for family members whose problems are of longer standing or who have already been exposed to relevant information.     

The 5-Step family intervention in primary care: I. Strengths and limitations according to family members

Background: Family members affected by a close relative's substance misuse constitute a large but neglected, high-risk group. Interventions for that group are now being developed and tested in trials. More use should be made of qualitative methods to study process in such interventions.

Design: Semi-structured interviews with family members 12 weeks after assignment to a full or brief 5-Step intervention. Both involved a primary care professional giving a self-help manual, and the full version also involved up to five sessions of a psychosocial intervention.

Participants: 143 patients of GPs, health visitors and practice nurses in general practices in two areas of England. Patients were the family members of close relatives with drinking or other drug problems.

Analysis: Framework analysis and grounded theory analysis of post-interview reports.

Results: There was strong support for a form of intervention that involved face-to-face discussion with a primary care professional, and those who received the full intervention were appreciative of being able to talk to a professional who had time to listen and who appeared interested, understanding and caring. The self-help manual itself was reported to contain active ingredients for change, and a number of family members described transformations in their ways of coping with the problem whether they received the full or brief form of intervention. A common constellation of changes included increased consciousness of the nature and extent of the relative's drinking or drug use and its family effects, an acknowledgement of the family member's own needs and rights, a strengthening of resolve to assert plans and expectations, and a calming effect with reduction in stress symptoms. Many participants were unable to describe changes, however, and the following principal limitations of the intervention were described: prior familiarity with the material, perception that the intervention did not go far enough, belief that it was incapable of effecting change for the substance misusing relative, and a perception that sufficient professional expertise or sympathy was not always available in primary care.

Conclusions: Findings suggest that the 5-Step family intervention has positive potential in the primary care setting, but has limitations and may need strengthening for family members whose problems are of longer standing or who have already been exposed to relevant information.     

Positive smoker identity as a barrier to quitting smoking: Findings from a national survey of smokers in England

Background

It has been proposed that positive smoker identity may be an important factor undermining smoking cessation but very little research exists on this. This study tested the hypothesis that a simple measure of positive smoker identity would predict quit attempts over and above other known predictors in a population sample. More tentatively it explored whether this measure would also predict quit success.

Methods

A representative sample of adult smokers in England (n = 9456) was included at baseline and 2099 were followed-up at six months. Demographic and smoking characteristics, a single item measure of positive smoker identity (endorsing the statement: ‘I like being a smoker’), measures of smoking-related attitudes, quit attempts and quit success were included.

Results

A total of 18.3% (95% CI = 17.5–19.2) of smokers reported a positive smoker identity. Adjusting for all other predictors, those with a positive smoker identity were more likely to be older (p < 0.001), male (p = 0.013), more nicotine dependent (p < 0.001), have lower motivation to stop (p < 0.001), have not made a quit attempt in the past year (p = 0.025), enjoy smoking (p < 0.001), and consider themselves to be addicted (p < 0.001). Having a positive smoker identity independently predicted failure to make a quit attempt at six months (p = 0.007). The independent association with quit success was similar in magnitude but did not reach statistical significance (p = 0.053).

Conclusions

Only a minority of smokers in England have a positive smoker identity. However, where it is present it may be an important barrier to quitting smoking and merits further study.     

Improving the capability to provide integrated mental health and substance abuse services in a state system of outpatient care

The paper reports on the capability of New York State (NYS) outpatient programs to provide integrated services for co-occurring disorders (COD). Assessments of 447 outpatient clinics, using two dual diagnosis capability indices (one used in addiction settings, the other in mental health settings), produced an overall score of 2.70, interpreted to position NYS clinics closer to “capable” (3.0 = Dual Diagnosis Capable) than to “basic” (1.0 = Alcohol [Mental Health] Only Services). “Assessment” and “Staffing” received the highest scores; i.e., clients with COD were usually identified, and staff (with some additional training and supervision) could treat both disorders effectively. While programs were generally prepared for clients with COD (e.g., welcoming such clients into the program, employing staff with competencies in both disorders, and having established routine screening and assessment to identify COD), results showed that the actual delivery of effective treatment was less satisfactory. The project demonstrated that COD capability can be assessed system-wide, using direct observation.     

Alcohol screening and alcohol interventions among patients with hypertension in primary health care: an empirical survey of German general practitioners

Background: Alcohol is one of the least intervened risk factors in the management of hypertension at the primary care level. In order to improve alcohol interventions, a better understanding of knowledge, attitudes and clinical practice of lifestyle interventions in the management of hypertension is needed.

Method: As a part of a European study (France, Germany, Italy, Spain, UK), 211 German general practitioners (GPs) were recruited in Bavaria and Hamburg and surveyed via an Internet-based questionnaire. Results were compared with the European sample (n?=?2870).

Results: One-third of the patients seen by German GPs had hypertension (36.2%, standard deviation (SD): 14.6) and among cases with hypertension, less than half were ever screened for alcohol (4.5 out of 10 patients). The foremost reasons for not screening for alcohol were that alcohol was not considered a major risk factor for hypertension plus the lack of knowledge of appropriate alcohol screening instruments. The majority of German GPs managed patients with hazardous drinking levels themselves or in their practice (71.3%, 95% confidence interval (CI): 64.6–77.2%), but only 42.0% (95% CI: 35.2–49.0%) managed alcohol dependent patients. German screening rates were slightly lower but interventions of screened positive patients higher than the European average.

Conclusions: Rates of alcohol screening in patients with hypertension in primary health care may be increased by improving GPs knowledge of alcohol as a major risk factor for hypertension, increasing GPs education on alcohol and screening instruments, and providing reimbursement. This may increase treatment of alcohol problems in patients with hypertension and reduce hypertension.