[Increasing trends in screening for addictives behaviors among general practitioners in France]

Obstacles and facilitators to preventing fetal alcohol spectrum disorder: a qualitative study with general practitioners

Background

Fetal Alcohol Spectrum Disorders are the leading cause of non-genetic intellectual disability. The damage caused, although completely preventable, is irreversible and requires lifelong support. General Practitioners have an important role in the prevention of Fetal Alcohol Spectrum Disorders. However, evidence suggests that General Practitioners do not monitor systematically alcohol consumption among pregnant women.

Objectives

The aim of this study was to understand the barriers and motivations of General Practitioners in the prevention of Fetal Alcohol Spectrum Disorders on Reunion Island.

Methods

A qualitative research study was conducted by conducting semi-structured individual interviews with general practitioners. Participants were selected by random or snowball sampling. General practitioners who worked only in unscheduled care services were excluded from this study. After the interviews were transcribed, a verbatim analysis was performed according to the principles of grounded theory.

Results

Twenty interviews were conducted by two researchers between November and December 2020. General practitioners expressed discomfort in addressing alcohol consumption and excessive drinking in women. They had inaccurate theoretical knowledge and a lack of practical experience with Fetal Alcohol Spectrum Disorders. They also showed little knowledge of the Fetal Alcohol Spectrum Disorders care pathway available on Reunion Island. Both patients and general practitioners expressed discomfort when discussing women's alcohol consumption. Conflicting government policies were highlighted as alcohol promotion campaigns overshadowed Fetal Alcohol Spectrum Disorders prevention initiatives.

Conclusion

General practitioners should be open and non-judgmental in their interactions with women and couples, with a focus on early detection and short-term intervention. General practitioners should be better educated about Fetal Alcohol Spectrum Disorders and have a clearer understanding of the Fetal Alcohol Spectrum Disorders care pathway.

Screening for alcohol use in primary care: assessing French general practitioner practices

Alcohol use is a leading risk factor for premature death and disability. To tackle this issue, more systematic and accurate screening for at-risk consumption is needed in healthcare systems, especially by general practitioners (GPs). We assessed the frequency of at-risk consumption screening by GPs in France. We also identified characteristics associated with more frequent screening and greater use of validated screening tools by these healthcare providers. A cross-sectional survey was conducted among a representative sample of French GPs. Multinomial logistic regressions were used to identify factors associated with more frequent screening and greater use of validated screening tools. Response rate was of 73%. Of the 2412 participants, 42.8% screened all their patients systematically and repeatedly, while 48.0% never used standardized tools to screen potentially at-risk patients. Among other characteristics, being aware of and using the "early identification and brief intervention" screening strategy, and feeling absolutely comfortable talking with patients about reducing or stopping their alcohol use, were both associated with more frequent screening and use of standardized tools. Our results on at-risk alcohol use screening highlight an improvement over data from previous studies. Nevertheless, better training of French GPs in good alcohol screening practices-specifically, increased screening frequency and greater use of standardized tools-may improve identification of at-risk patients.

Barriers and Expectations of Adolescents Regarding the Identification and Management of Their Psychoactive Substance Use by Their General Practitioner

AIMS

General practitioners (GPs), who are the most frequently consulted health professionals by adolescents, play a key role in screening for psychoactive substance (PAS) use. The purpose of our study was to determine the barriers and expectations of adolescents regarding the identification and management of their PAS use by their general practitioner.

METHODS

Descriptive, cross-sectional study of a population of adolescents aged 12 to 17 years, followed up in general practice in France. Adolescents were recruited from general practice offices by open-access questionnaires. An opaque box was provided to ensure the anonymity of the adolescents.

RESULTS

A total of 277 adolescents were included: 155 girls, mean age 14.5 ± 1.7 years, 113 adolescents (41%) had used a PAS at least once in the past 12 months. Alcohol was the most used PAS, followed by tobacco and cannabis. Three groups were identified: the nonusers group (n = 134); the group of moderate users (n = 71); the group of users at risk of substance abuse or misusing (n = 38). Regardless of group, adolescents felt that their GP was attentive, responsive, competent, understanding, and took the time to ask the appropriate questions in their role. The at-risk group was less confident and less comfortable, and they felt more judged and more afraid of the GP telling their parents. Despite this, the at-risk group was the most willing to talk to their GP about their PAS. Almost half of the adolescents surveyed found it useful to use a questionnaire to discuss PAS.

CONCLUSIONS

Reminding each consultation of the principles of the relationship of trust and confidentiality while maintaining an empathetic attitude would make it easier for GPs to remove adolescents' inhibitions about communicating about their PAS use.

Discussing alcohol use with the GP: a qualitative study

BACKGROUND

Despite most GPs recognising their role in the early diagnosis of alcohol use disorder (AUD), only 23% of GPs routinely screen for alcohol use. One reason GPs report for not screening is their relationship with patients; questions regarding alcohol use are considered a disturbance of a relationship built on mutual trust.

AIM

To analyse the feelings and experiences of patients with AUD concerning early screening for alcohol use by GPs.

DESIGN & SETTING

A qualitative study of patients (n = 12) with AUD in remission or treatment, recruited from various medical settings.

METHOD

Semi-structured interviews were conducted, audiorecorded, and transcribed verbatim. The authors conducted an inductive analysis based on grounded theory. The analysis was performed until theoretical data saturation was reached.

RESULTS

The participants experienced AUD as a chronic, destructive, and shameful disease. The participants expected their GPs to play a primary role in addressing AUD by kind listening, and providing information and support. If the GPs expressed a non-judgmental attitude, the participants could confide in them; this moment was identified as a key milestone in their trajectory, allowing relief and a move toward treatment. The participants thought that any consultation could be an opportunity to discuss alcohol use and noted that such discussions required a psychological and benevolent approach.

CONCLUSION

The participants felt fear or denial from the GPs, even though they felt that discussing alcohol use is part of the GP's job. The participants requested that GPs adopt non-judgmental attitudes and kindness when approaching the subject of alcohol use.

Screening and care for alcohol use disorder in France: expectations, barriers and levers using a mixed-methods approach

Background

The widespread under-screening and under-treatment of alcohol use disorder (AUD) contributes to its health and socioeconomic burden. We conducted a mixed-methods (qualitative and qualitative) study in people with alcohol use disorder (PWAUD) to explore their expectations, as well as barriers and levers to AUD care.

Methods

Individuals with AUDIT > 15 (N = 179) were interviewed using computer-assisted interviews in several medical and non-medical sites (e.g., bars) (quantitative substudy). We also conducted semi-structured face-to-face interviews with 36 PWAUD (qualitative substudy). Using logistic regression, we explored factors associated with having previously received/sought care for AUD. Three major themes were identified in the qualitative textual analysis using a descending hierarchical classification.

Results

Not socializing with heavy drinkers (AOR [95%CI]:3.84[1.66–8.85]), regular smoking (9.72[3.91–24.15]) and feeling discriminated against (2.35[1.10–5.05]) were independent levers to having sought/received care for AUD, while being aged < 50 and employment were independent barriers. The five predominant themes in PWAUD discourses emerging from the textual analysis were: drinking context, medical care, alcohol treatment, tobacco/addiction and family. When triangulating results from the logistic regression and the textual analysis, two barriers (social drinking and difficulties with the medical care system), and two levers (family influence and tobacco addiction), emerged.

Conclusion

These results underline the need for interventions targeting families and the social network to increase awareness about AUD and related care. Simplified and novel comprehensive care trajectories are urgently needed to reduce the clinical and public health burden of AUD.

Untreated alcohol use disorder in people who inject drugs (PWID) in France: a major barrier to HCV treatment uptake (the ANRS-FANTASIO study)

BACKGROUND AND AIMS

Although people who inject drugs (PWID) are the core at-risk population in the hepatitis C virus (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well-tolerated HCV treatments (direct-acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon-based treatments: Peg-IFN).

DESIGN

Using discrete-time Cox proportional hazards models based on exhaustive care delivery data, we tested for associations between AUD (defined by AUD-related long-term illness status, diagnosis coding during hospitalization and/or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of opioid agonist therapy (OAT) received. Separate analyses were performed for 2012-13 (Peg-IFN era) and 2014-16 (DAA era).

SETTING

France.

PARTICIPANTS

All French people chronically HCV-infected who received OAT at least once during 2012-16 and were covered by the national health insurance (n = 24 831).

MEASUREMENTS

Incidence rate of HCV treatment uptake, hazard ratios associated with AUD and other covariates.

FINDINGS

Incidence rate (IR) of HCV treatment uptake per 100 person-years was 6.56, confidence interval (CI) = 6.30-6.84; and IR = 5.70, 95% CI = 5.51-5.89 for Peg-IFN-based treatment (2012-13) and DAA (2014-16), respectively. After multiple adjustment, people with AUD not receiving related medication had 30 and 14% lower Peg-IFN-based treatment and DAA uptake, respectively, than those without AUD [hazard ratio (HR) = 0.70, 95% CI = 0.62-0.80 and HR = 0.86, 95% CI = 0.78-0.94]. No difference was observed between those treated for AUD and those without AUD.

CONCLUSIONS

Despite the benefits of direct-acting antiviral treatment, untreated alcohol use disorder appears to remain a major barrier to hepatitis C virus treatment access for people who inject drugs in France.

Cannabis users: Screen systematically, treat individually. A descriptive study of participants in a randomized trial in primary care

Purpose

The aim of the present study was to describe the profiles of a sample of young cannabis users not seeking care, for use in general practice in France.

Methods

In this cross-sectional study, baseline data were used from a previous clinical randomized trial, in which a brief intervention was tested. The participants were 262 cannabis users aged 15 to 25 years who smoked at least one joint per month. Assessment was undertaken both by the GP and via an anonymous self-reporting questionnaire. All statistical analyses were performed using Stata software and R. We used multiple correspondence analysis to determine the profiles of users.

Results

Among the 262 patients, 46.2% were daily users (more than 30 joints per month), 25.6% were regular users (from 10 to 29 joints per month), and 28.2% were recent users (fewer than 10 joints per month). The higher the frequency of use, the greater the incidence of unaccompanied use, daily use and week use (p from <0.001 to 0.01). The motivations of daily users were mostly self-treatment and habit (p <0.05). The cannabis abuse screening trial score revealed risky use for 87.5% of daily users and 34.4% for recent users. Factorial analysis identified 5 profiles according to age, risk, and motive for use. The reasons for consultation were equally distributed among users regardless of their level of use or their profile (p > 0.05).

Conclusions

The results provide support for the practice of asking young patients systematically about their cannabis use, allowing GPs to identify users who require medical care. GPs should consider the differences between participants according to their profile in order to determine the appropriate type of care.

Trial registration

Clinicaltrials.gov NCT01433692.

Development and validation of a virtual agent to screen tobacco and alcohol use disorders

BACKGROUND

Substance use disorders are under-detected and not systematically diagnosed or screened for by primary care. In this study, we present the acceptability and validity of an Embodied Conversational Agent (ECA) designed to screen tobacco and alcohol use disorder, in individuals who did not seek medical help for these disorders.

METHODS

Individuals were included from June 2016 to May 2017 in the Outpatient Sleep Clinic of the University Hospital of Bordeaux. DSM-5 diagnoses of tobacco and alcohol use disorders were assessed by human interviewers. The ECA interview integrated items from the Cigarette Dependence Scale-5 (CDS-5) for tobacco use disorder screening, and the "Cut Down, Annoyed, Guilty, Eye-opener" (CAGE) questionnaire for alcohol use disorder screening. Paper version of CDS-5 and CAGE questionnaires and acceptability questionnaire was also self-administered.

RESULTS

Of the 139 participants in the study (mean age 43.0 [SD = 13.7] years), 71 were women, and 68 were men. The ECA was well accepted by the patients. Paper self-administered CDS-5 and CAGE scores had a strong agreement with the ECA (p < 0.0001). The Receiver Operating Characteristic (ROC) analysis of the ECA interview showed AUC of 0.97 (95% CI, 0.93-1.0) and 0.84 (95% CI, 0.69-0.98) for CDS-5 and CAGE respectively with p-value <0.0001.

CONCLUSIONS

This ECA was acceptable and valid to screen tobacco or alcohol use disorder among patients not requesting treatment for addiction. The ECA could be used in hospitals and potentially in primary care settings to help clinicians to better screen their patients for alcohol and tobacco use disorders.

The practices of French general practitioners regarding screening and counselling pregnant women for tobacco smoking and alcohol drinking

OBJECTIVES

Our study aims to describe French general practitioners' (GPs') practices toward pregnant patients regarding alcohol consumption and smoking and to highlight factors associated with specific practices.

METHODS

In 2015, a representative sample of 1414 French GPs completed a telephone survey based on a stratified random sampling.

RESULTS

61% of GPs declared screening for alcohol use and 82% for smoking at least once with each pregnant patient; quitting was not systematically advised either for alcohol or for smoking. GPs' practices were significantly better among those who had more recent ongoing training. GPs who drank regularly were less likely to screen for alcohol use and GPs' drinking frequency was inversely related to recommending quitting. Current and former smokers were less likely to recommend quitting to pregnant patients smoking over five cigarettes per day.

CONCLUSIONS

Screening and counselling practices for substance use during pregnancy are heterogeneous among French GPs and are notably related to their personal consumption. GP's role in preventing substance use during pregnancy could be strengthened by actions regarding their own consumption and by modifications in their initial and ongoing training.

[Cannabis use: what to do in general practice?]

Cannabis use is now more frequent than alcohol drinking or tobacco smoking among young people (15-34years), whereas it may induce numerous medical aftermaths. Identifying and assessing cannabis use in general practice have become a current public health issue. The two steps of screening consist in spotting risky use of cannabis, and then in checking criteria for cannabis use disorder (CUD). Risky use requires a "brief intervention" by the general practitioner (GP). In case of CUD, the new DSM-5 criteria allow measuring the severity of the subsequent disorder, and listing the medical and social consequences. Using these criteria can help the GP to decide when the patient should be referred to an addiction-specialized unit. The GP has also to spot the different physical and psychiatric complications of cannabis use, in order to coordinate care between the different specialists.

Attitudes of family physicians towards adolescent cannabis users: a qualitative study in France

BACKGROUND

GPs are the health professionals most frequently consulted by adolescents. However, discussion between GPs and adolescents regarding cannabis use does not occur spontaneously.

OBJECTIVE

To identify obstacles to the identification and management of cannabis use by adolescents based on GPs' experiences.

METHODS

We conducted a qualitative study using focus groups of GPs from the Auvergne area (France). The GPs were selected according to descriptive and strategic variables. Three researchers--an anthropologist, a psychiatrist with expertise in addiction and a GP--performed a thematic analysis.

RESULTS

Twenty-four GPs participated in three consecutive focus groups. The GPs were aware of the health risks of cannabis, yet ambivalent about its use by adolescents. The GPs also reported a lack of patient questioning during consultation. The obstacles to the identification and treatment of cannabis use by adolescents identified included lack of GP knowledge about cannabis (e.g. consumption patterns and laws); difficulties in addressing the issue with adolescents, evaluating adolescents' consumption and its impact and proposing support and follow-up and the presence of parents. The GPs were aware that their role lies at the intersection between the medical, personal, familial and social fields.

CONCLUSION

Despite these barriers, GPs are willing to ask adolescents about their cannabis use. An adolescent's awareness, environment and receptiveness favour a sustainable therapeutic relationship. Brief intervention is a tool that may be of assistance in this relationship and allow GPs to take the initiative.

Baclofen for alcohol dependence in France: incidence of treated patients and prescription patterns--a cohort study

Recently, baclofen has been widely promoted for treatment of alcohol dependence in France. Our aim was firstly to describe the incidence of patients newly treated with baclofen for alcohol dependence in France from 2007 to 2011, and secondly to describe baclofen prescription patterns and prescribers. A retrospective cohort study of patients newly treated with baclofen was conducted using the "Echantillon Généraliste des Bénéficiaires" database (EGB). Patients with a first dispensation of baclofen between 01/01/2007 and 31/12/2011, followed by a second in the next 120 days, were included. Patients were considered treated with baclofen for neurological conditions if at least one of the following conditions was found to be true: (1) presence of a neurological condition for which baclofen could be prescribed, (2) dispensation of dantrolene, another anti-spastic drug, or (3) hospitalization for a neurological condition for which baclofen could be prescribed. We assumed that all the remaining patients were treated for alcohol dependence. During the 5-year period, 676 patients were incident users. While the annual incidence rate of patients newly treated with baclofen for neurological conditions remained stable, the annual incidence rate of patients newly treated with baclofen for alcohol dependence increased by a factor of 2.9 between 2007 (0.09/1000 person-years) and 2011 (0.26/1000 person-years). In the alcohol dependence group, median duration of baclofen treatment was 143.5 [74.0; 377.0] days; median daily dose was 24.4 [14.8; 39.5] mg. This study demonstrated the rapidly increasing use of baclofen in France for treatment of alcohol dependence.

CANABIC: CANnabis and Adolescents: effect of a Brief Intervention on their Consumption--study protocol for a randomized controlled trial

BACKGROUND

Cannabis is the most consumed illegal substance in France. General practitioners (GPs) are the health professionals who are most consulted by adolescents. Brief intervention (BI) is a promising care initiative for the consumption of cannabis, and could be a tool for GPs in caring for adolescents who consume cannabis. The aim of the CANABIC study is to measure the impact of a BI carried out by a GP on the consumption of cannabis by adolescents of 15 to 25 years of age.

METHODS

A randomized clustered controlled trial, stratified over three areas (Auvergne, Languedoc-Roussillon, and Rhône - Alpes), comparing an intervention group, which carries out the BI in consultation, and a control group, which ensures routine medical care. The main assessment criterion is the consumption of cannabis by amount of joints per month, at 12 months. The amount necessary to highlight a significant difference between the two groups of 30% of consumption at 12 months is 250 patients (50 GPs, 5 patients per GP; risk α = 5%; power = 90%; intra-cluster correlation coefficient ρ = 0.2; Hawthorne effect = 15%; lost to follow-up rates for GPs = 10% and for patients = 20%). This plan is replicated for the three areas, and therefore a total of 750 patients are expected.The secondary criteria for judgment are the associated consumption of tobacco and alcohol, the perception of the consequences of consumption, and the driving of a vehicle following consumption.

DISCUSSION

Research about BI for young cannabis users is underway. The aim of the CANABIC study is to validate a BI suited to adolescents who consume cannabis, which may be performed in the general practice. This would provide a tool for their treatment by a GP, which could be widely distributed during initial or further medical training.

TRIAL REGISTRATION

CANABIC is a randomized clustered trial (NCT01433692, registered 2011 Sept 12), PHRC funded: Clinical Research Hospital Program (Governmental Fund, Health Ministry). Date first patient randomized: March 2012.

A survey of French general practitioners and a qualitative study on their use and assessment of predictive clinical scores

BACKGROUND

Predictive clinical scores, diagnostic as well as prognostic, are considered to be useful tools for making decisions under conditions of uncertainty. They are not intended to replace clinical judgment or medical experience, but to help physicians in the interpretation of clinical information. The general practitioner (GP), the gateway to care in the French health system, should be the main beneficiary of their utilization. However, there is no information on the prevalence of their use in general practice in France.

METHODS

A national, transversal epidemiological survey was conducted by electronic mail among GPs belonging to the French Sentinelles network. GPs were asked about their use of scores, the context of their utilization and the expected benefit. A qualitative study (focus groups) was also carried out with three groups of GPs within the context of continuous medical education.

RESULTS

The study consisted of 358 GPs. They were questioned on their use of seven predictive clinical scores (six diagnostic and one prognostic). Clinical scores were used by 75% of GPs, with no statistical difference with regard to their age or sex. The most often used were: the Mini Mental Status Examination (MMSE) (95%), Fagerström test (90%), Hamilton scale (65%), McIsaac scores (61%), DETA/CAGE (45%), Simple Calculated Osteoporosis Risk Estimation (SCORE) for osteoporosis (33%), and the only prognostic score CHADS2 (28%). Clinical scores were especially used when elderly people were involved (77%) and when the diagnosis was uncertain (63%). The qualitative study gave additional information on the barriers and obstacles to the use of predictive clinical scores.

CONCLUSION

This study, the first one in France, gives information on the perception of clinical scores and on the rationale for their use by GPs. Suggestions to improve the situation (availability and rate of utilization of clinical scores) are provided.