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The United States Preventive Services Task Force recommends that primary care clinicians assume a major role in screening, identification, treatment, and referral to treatment of unhealthy alcohol and other drug (AOD) use—the spectrum from use that risks health consequences to AOD disorders (abuse and dependence)—in generalist settings.1 In the United States, nicotine dependence, alcohol use, and drug use are the first, third, and ninth leading causes, respectively, of preventable deaths.2 Despite the harmful effects of addiction and improved options for office-based treatments and referral, not all primary care clinicians routinely address AOD use in their patients. The objectives of this paper are to identify and examine important recent advances in addiction medicine that have implications for primary care clinicians and that emphasize primary care clinicians’ role in the identification, treatment and/or referral of patients with addictions. We conducted an electronic database (PubMed) search to systematically identify recent (June 1, 2006 to January 1, 2008) human subject, English language, peer-reviewed, research publications that are relevant to generalist care for patients with addiction disorders. We also surveyed the publications that were reviewed by a NIH-funded newsletter that, in an attempt to identify articles that address the health impact of alcohol and drugs, systematically reviews the core general medical, infectious disease, public health, and addiction subspecialty journals.3 Similar to our prior review,4 authors (A.G., D.F., R.S.) were provided a title listing of articles with addiction-related key words within the reference time frame, and then secondary searches and consensus deliberations were used to identify articles that may impact the care provided by primary care clinicians in the categories of 1) alcohol use and disorders and 2) opioid use and dependence. Articles were categorized as impacting primary care clinicians if they studied primary care settings or could impact such settings and had practice-changing findings or implications.

To evaluate whether training primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior.We randomized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 (1/4) hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have "made a change in their drinking and are trying to keep it that way"; and that they drank15 (men) or10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit.Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit.Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry.

BACKGROUND: This study assesses the rate and predictors of treatment retention for primary care patients with opioid dependence-prescribed buprenorphine, a long-acting partial opioid agonist. METHODS: Observational cohort study of patients prescribed buprenorphine/naloxone and followed for 6 months in the period after the adoption of buprenophine/naloxone by a primary care practice in Rhode Island. Practice policy precluded patient discharges due to continuing drug use. RESULTS: Patients (n=41) had a mean duration of opioid use of 15.7 years and most had a history of heroin use (63.4%). Thirty-nine percent of patients transferred from methadone maintenance. At 24 weeks, 59% remained in treatment. Nearly half of dropouts occurred in the first 30 days. Participants with opiate-positive toxicologies at week 1 were more likely to drop out of the program (P

OBJECTIVE: To examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients’ addiction severity and medical outcomes, compared to programs that offer no primary care.

Domestic violence has an estimated 30% lifetime prevalence among women, yet physicians detect as few as 1 in 20 victims of abuse.To identify factors associated with physicians' low screening rates for domestic violence and perceived barriers to screening.Cross-sectional postal survey.A national systematic sample of 2,400 physicians in 4 specialties likely to initially encounter abused women. The overall response rate was 53%.Self-reported percentage of female patients screened for domestic violence; logistic models identified factors associated with screening less than 10%.Respondent physicians screened a median of only 10% (interquartile range, 2 to 25) of female patients. Ten percent reported they never screen for domestic violence; only 6% screen all their patients. Higher screening rates were associated with obstetrics-gynecology specialty (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.31 to 0.78), female gender (OR, 0.51; CI, 0.35 to 0.73), estimated prevalence of domestic violence in the physician's practice (per 10%, OR, 0.72; CI, 0.65 to 0.80), domestic violence training in the last 12 months (OR, 0.46; CI, 0.29 to 0.74) or previously (OR, 0.54; CI, 0.34 to 0.85), and confidence in one's ability to recognize victims (per Likert-scale point, OR, 0.71; CI, 0.58 to 0.87). Lower screening rates were associated with emergency medicine specialty (OR, 1.72; CI, 1.13 to 2.63), agreement that patients would volunteer a history of abuse (per Likert-scale point, OR, 1.60; CI, 1.25 to 2.05), and forgetting to ask about domestic violence (OR, 1.69; CI, 1.42 to 2.02).Physicians screen few female patients for domestic violence. Further study should address whether domestic violence training can correct misperceptions and improve physician self-confidence in caring for victims and whether the use of specific intervention strategies can enhance screening rates.

To describe adult primary care physicians' and psychiatrists' approach to alcohol screening and treatment, and to identify correlates of more optimal practices.Cross-sectional mailed survey.A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry.Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales.Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object.Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols or offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians' screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement

This study assesses the rate and predictors of treatment retention for primary care patients with opioid dependence-prescribed buprenorphine, a long-acting partial opioid agonist.Observational cohort study of patients prescribed buprenorphine/naloxone and followed for 6 months in the period after the adoption of buprenophine/naloxone by a primary care practice in Rhode Island. Practice policy precluded patient discharges due to continuing drug use.Patients (n=41) had a mean duration of opioid use of 15.7 years and most had a history of heroin use (63.4%). Thirty-nine percent of patients transferred from methadone maintenance. At 24 weeks, 59% remained in treatment. Nearly half of dropouts occurred in the first 30 days. Participants with opiate-positive toxicologies at week 1 were more likely to drop out of the program (P.01) and had a significantly shorter retention time (P.01) on average. Among other drug use and drug treatment variables, employment and addiction counseling during treatment were significantly associated with treatment retention (P=.03).Retention rates in a real world, primary care-based buprenorphine maintenance practice reflect those reported in clinical trials. Abstinence during the first week of treatment and receipt of counseling were critical to patient retention.

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients' family history. Physicians were less likely (P < .05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.

To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.Survey of a national systematic sample of physicians.Five hundred family practitioners, 500 general internists, and 500 cardiologists.Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (por = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [por = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%).Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.