Substance use disorder in the anaesthetist: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6-10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.

Adverse physical effects of alcohol misuse

This article outlines the majority of the adverse physical effects that have been described secondary to the consumption of alcohol at levels above recommended sensible limits. These conditions are cited according to the organ system they belong to. Only brief descriptions are provided because of the vastness of this topic. The underlying pathophysiology of tolerance and withdrawal is touched upon as this is of relevance to the psychiatrist. Definitions of the terms used describing alcohol misuse, and sensible upper limits of alcohol consumption are also mentioned.

Awareness of Medical Fitness to Drive Guidelines among Occupational Physicians and Psychiatrists

Irrespective of national guidelines for medical fitness to drive, this study investigated the cumulative expert wisdom of clinicians regarding minimum periods of driving cessation required for patients suffering from conditions that can impair driver capability. Occupational Physicians (196) and Psychiatrists (103) completed an online questionnaire. For private motorists, the modal response for anxiety and depression favoured clinical discretion, followed by three month cessations for hypomania, acute psychosis, schizophrenia and alcohol dependence and six weeks for alcohol misuse/dependence. For professional drivers the modal value for anxiety and depression was three months, rising to six months for hypomania, psychosis and schizophrenia and 12 months for both alcohol misuse/dependence. Chi-square test results indicated statistically significant differences in clinical opinion between Occupational Physicians and Psychiatrists regarding driving cessation times for drivers suffering from psychiatric and alcohol misuse conditions except for alcohol dependence. Further studies are warranted to investigate these issues in more depth.

Risk factors and medical follow-up of drug users tested for hepatitis C--can the risk of transmission be reduced?

Of 1728 patients attending a regional drug and alcohol clinic, 202 were considered at risk of hepatitis C virus (HCV). Forty-nine per cent (99/202) agreed to testing-67% (67) were HCV antibody positive. Age and a history of needle sharing was the significant factor associated with positive HCV status. Patients on methadone maintenance medication were more-likely to have been HCV positive, but significantly (p = 0.005) less likely to have shared needles in the previous year. Seventy-three per cent (49/67) attended for follow-up at a "liver clinic". Fifty per cent were infected with genotype 1a. Eighteen patients were biopsied and all were abnormal, ranging from mild hepatitis to severe fibrotic hepatitis. Attendance for medical follow-up was poor, which emphasizes the importance of preventative measures such as methadone maintenance programmes for reducing the spread of HCV.

Managing chronic hepatitis C acquired through intravenous drug use

We retrospectively reviewed the provision and uptake of hospital services for 253 current and ex-intravenous drug users with hepatitis C virus (HCV). Overall, 237 attended at least one clinic (mean age 32 years, 70% male, 43% on maintenance methadone); 81% had evidence of active viral replication and 137 agreed to a liver biopsy to assess disease severity. Of these 137, 24% had mild chronic hepatitis with a low risk of progression to cirrhosis, but 9% had cirrhosis (mean age 40 years, mean time since initial intravenous drug use 15.8 years). Only 50 of the 100 patients in whom antiviral therapy was indicated, commenced treatment; 18 (36%) have had a sustained virological response. The natural history or response to treatment of chronic HCV in those who acquire it through intravenous drug use is not different to that previously reported for post-transfusion HCV. However, a substantial proportion default from follow-up or decline further intervention. As intravenous drug use is now the main risk factor for acquisition of HCV, these data have implications for future delivery of care aimed at limiting the morbidity of chronic HCV, and limiting the spread of hepatitis C virus infection amongst intravenous drug users.

International variations in youth drug use: the effect of individual behaviours, peer and family influences, and geographical location

This international study investigates factors underlying international variations in rates of youth drug use among representative samples of 15-year-olds in five cities (Bremen, n = 871; Dublin, n = 983; Groningen, n = 487; Newcastle upon Tyne, n = 880; Rome, n = 666). It reveals a higher level of drug use in English-speaking compared to continental populations. Drug use was associated with peer, family and individual factors. Logistic regression showed that family structure and sport were associated with lower rates and delinquent behaviour with higher rates of drug use in all cities and among males and females. Among males, city of residence also independently predicted drug use. The effect of traditional families and studiousness in reducing drug use was most evident for male drug use in low-use cities: higher rates of use in English-speaking cities appear partially due to the drug use of low-risk males.

Interleukin 10 promoter region polymorphisms and susceptibility to advanced alcoholic liver disease

BACKGROUND

The factors determining why less than 10% of heavy drinkers develop advanced alcoholic liver disease (ALD) remain elusive, although genetic factors may be important. Interleukin 10 (IL-10) is an important cytokine with anti-inflammatory, anti-immune, and antifibrotic functions. Several polymorphisms have been identified in the IL-10 promoter and recent evidence suggests that some of these may have functional effects on IL-10 secretion.

AIMS

To test the hypothesis that IL-10 promoter region polymorphisms are associated with susceptibility to ALD.

METHODS

The allele frequencies for the two single base pair substitutions at positions -627 (C-->A) and -1117 (A-->G) in the IL-10 promoter were determined in 287 heavy drinkers with biopsy proved advanced ALD, 107 heavy drinkers with no evidence of liver disease or steatosis only on biopsy, and 227 local healthy volunteers.

RESULTS

At position -627, 50% of patients with advanced ALD had a least one A allele compared with 33% of controls (p<0.0001) and 34% of drinkers with no or mild disease (p=0.017). At position -1117, the slight excess of the A allele in drinkers with advanced disease was because of linkage disequilibrium between the A alleles at the two sites.

CONCLUSIONS

Among heavy drinkers, possession of the A allele at position -627 in the IL-10 promoter is associated with an increased risk of advanced liver disease. This is consistent with recent functional data that the -627*A allele is associated with low IL-10 expression which will favour inflammatory, immune mediated, and profibrotic mechanisms of alcohol related liver injury.

Changes in receptionists' attitudes towards involvement in a general practice-based trial of screening and brief alcohol intervention

BACKGROUND

Primary health care receptionists are increasingly expected to be involved in research. However, little is known about receptionists' attitudes to research or health programmes.

AIM

To examine changes in receptionists' attitudes, with different levels of training and support, towards involvement in a general practice-based trial of screening and brief alcohol intervention.

METHOD

Subjects were 84 receptionists, one per practice, who assisted in the implementation of a screening and brief alcohol intervention programme. Receptionists were randomly assigned to one of three conditions: control (no training or support), training alone, and training plus ongoing telephone support. Baseline and follow-up questionnaires were used to assess changes in receptionists' attitudes.

RESULTS

Of 40 items that measured receptionists' attitudes to involvement in the programme, 70% had deteriorated after three months, 20% significantly so. There was no effect of training and support condition. Receptionists' and GPs' attitudes to research and health programmes conflicted.

CONCLUSION

Receptionists developed more negative views about involvement in research and health programmes over the three-month study period, regardless of level of training and support.

Substance abuse in young people

Adolescent substance abuse, with its heterogeneity, its complexity and its association with behavioural, physical and mental health problems is of increasing interest to many; the politician, the economist, clinicians and researchers, families and young people themselves. Data concerning the prevalence and trends in use of a range of substances in different countries, cultures and different groups are reviewed. The influence of associated mental and physical health problems, the multiple definitions applied to use and abuse and the confounding effect of different ideologies and cultural differences are considered. There is now much interest in the understanding of risk and protective influences, including multi focused prevention programmes among vulnerable young people. Some positive effects of universal prevention programmes are reported, although too often they lack thoroughness in programme implementation, data collection and follow up. Indeed compared to the adult addiction literature there is a death of research on adolescent treatment outcomes. Research needs to address treatment and cost effectiveness in different settings with different groups. The evidence tends to support multi faceted interventions for high risk youths. However, the use of evidence based programmes with a scientific basis should be supported and implemented.

A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners

BACKGROUND

Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice. An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines.

AIM

To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention (SBI) by general practitioners (GPs).

METHOD

Subjects were 128 GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority, who agreed to use the 'Drink-Less' SBI programme in an earlier dissemination trial. GPs were stratified by previous marketing conditions and randomly allocated to three intensities of training and support: controls (n = 43) received the programme with written guidelines only, trained GPs (n = 43) received the programme plus practice-based training in programme usage, trained and supported GPs (n = 42) received the programme plus practice-based training and a support telephone call every two weeks. GPs were requested to use the programme for three months. Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with.

RESULTS

Seventy-three (57%) GPs implemented the programme and screened 11,007 patients for risk drinking. Trained and supported GPs were significantly more likely to implement the programme (71%) than controls (44%) or trained GPs (56%); they also screened, and intervened with, significantly more patients. Costs per patient screened were: trained and supported GPs, 1.05 Pounds; trained GPs, 1.08 Pounds; and controls, 1.47 Pounds. Costs per patient intervened with were: trained and supported GPs, 5.43 Pounds; trained GPs, 6.02 Pounds; and controls, 8.19 Pounds.

CONCLUSION

Practice-based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs.

A randomized trial of three marketing strategies to disseminate a screening and brief alcohol intervention programme to general practitioners

BACKGROUND

Research findings are of little benefit to patients or society if they do not reach the audience they are intended to influence. A dissemination strategy is needed to target new findings at its user group and encourage a process of consideration and adoption or rejection.

AIM

To evaluate the effectiveness and cost-effectiveness of different marketing strategies for the dissemination of a screening and brief alcohol intervention (SBI) programme to general practitioners (GPs).

METHOD

Seven hundred and twenty-nine GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority were randomly assigned to one of three marketing strategies: postal marketing (mailing a promotional brochure to GPs), telemarketing (following a script to market the programme over the telephone), and personal marketing (following the same script during face-to-face marketing at GPs' practices). GPs who took up the programme were asked if they would agree to use it. Outcome measures included the proportions of GPs who took up the programme and agreement to use it.

RESULTS

Of the 614 GPs eligible for the study, 321 (52%) took the programme. There was a significant difference in the proportions of GPs from the three marketing strategies who took the programme (82% telemarketing, 68% personal marketing, and 22% postal marketing). Of the 315 GPs who took the programme and were eligible to use it, 128 (41%) agreed to use the programme for three months. GPs in the postal marketing group were more likely to agree to use the programme (55% postal marketing, 44% personal marketing, and 34% telemarketing). Personal marketing was the most effective overall dissemination strategy; however, economic analysis revealed that telemarketing was the most cost-effective strategy. Costs for dissemination per GP were: 13 Pounds telemarketing, 15 Pounds postal marketing, and 88 Pounds personal marketing.

CONCLUSION

Telemarketing appeared to be the most cost-effective strategy for dissemination of SBI to GPs.

Specialist services: the need for multi-agency partnership

In the UK the broad trend noted in prevalence surveys is towards increased availability, exposure, and use of illicit drugs across all social strata. There is a developing consensus regarding those groups of young people who are at particular risk. They may be homeless, pregnant, leaving local authority or foster care, engaged in prostitution or involved with the criminal justice system. These young people are likely to require intervention from a variety of agencies and professionals to respond to their multiple needs, yet they are faced with a dearth of specialist substance misuse services. Consequently there is a need to develop a range of partnership approaches amongst both providers and commissioners of services. The importance of partnership has been stressed in a succession of professional guidance documents, but there remain considerable bureaucratic, organisational, and historical barriers that must be overcome. Effective service models that exist in the UK and elsewhere are a source of ideas to stimulate appropriate, child-centred developments. Overall the need for a fresh impetus is emphasised, in which new partnerships are formed, and collaborative services are developed and evaluated. In this way future initiatives can be based upon evidence of clinical and cost effectiveness.

Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners

General practitioners' (GPs') recognition of, attitudes towards, and intervention for, excessive drinking and alcohol problems among their patients were assessed in a postal questionnaire survey. Levels of recognition of, and intervention for, excessive drinking by GPs were low. GPs did not routinely enquire about alcohol and had managed only small numbers of patients specifically for excessive drinking or alcohol problems in the previous year. Enquiry about alcohol issues was elicited mainly by physical symptoms or by new patient registrations. Although 83% of GPs felt prepared to counsel excessive drinkers, only 21% felt effective in helping patients reduce consumption. Over the past 10 years, there appears to have been an increase in numbers of GPs who feel that they should be working with alcohol issues, but fewer GPs perceive themselves as being effective in this work. The main barriers to brief alcohol intervention were given as insufficient time and training, and lack of help from government policy; the main incentives related to availability of appropriate support services and proven efficacy of brief interventions.

Our Healthier Nation: are general practitioners willing and able to deliver? A survey of attitudes to and involvement in health promotion and lifestyle counselling

BACKGROUND

The recent Green Paper, Our Healthier Nation, identifies professional advice on healthier living as a key component of its national contract for health. General practitioners (GPs) are ideally placed for this work. However, previous research has reported a discrepancy between patients' expectations of lifestyle advice from GPs and their receipt of such advice.

AIMS

To describe GPs' current attitudes to and involvement in health promotion and lifestyle counselling, and to track changes in these areas over recent years.

METHOD

A postal questionnaire survey of a random sample of 430 GPs, one per practice, from all general practices in Leicestershire, Derbyshire, and Nottinghamshire. GPs who had not responded after two weeks received a reminder telephone call plus two follow-up questionnaires.

RESULTS

Four hundred and eleven GPs were eligible for the survey, which yielded a response rate of 68% (n = 279). GPs reported spending an average 16% of practice time on prevention and 79% reported educating patients about lifestyle risk 'most' or 'all of the time'. Solo GPs spent more time on prevention than GPs from group practices. Most enquiries and interventions related to smoking behaviour. GPs felt most effective in changing patients' use of prescription drugs, and the largest reported difference between current and potential effectiveness in helping patient change lifestyle behaviour, after information and training, related to reducing alcohol consumption.

CONCLUSIONS

Despite an increasing workload, GPs remain positive about health promotion and lifestyle counselling. Over the past 10 years, there has been an increase in routine enquiries about lifestyle behaviour, but confidence about effectiveness in helping patients changes lifestyle behaviour remains low. More training and support concerning lifestyle intervention is required by GPs in order for them to contribute effectively to the Government's health promotion programme.

Managing anxiety and depression in alcohol and drug dependence

Previous research has highlighted the high prevalence (30-60%) of comorbid anxiety and mood disorders in clients with substance misuse disorders and, equivalently, a third of those with affective disorder report a history of substance use disorder (Kessler et al., 1994; Regier et al., 1990; Robins & Regier, 1991). This article reviews the management of such cases and identifies key issues in the assessment process, as well as potential avenues for treatment. Other articles have highlighted the increased service utilisation and the cost of care and treatment of comorbidity. This article will primarily focus on the management of individual cases and will briefly refer to issues of service organisation. Although antidepressant or anxiolytic pharmacotherapy may have a role in the treatment of severe disorders, the benefits of using these medications must be balanced against the increased risk of side-effects or adverse reactions in individuals who continue to engage in substance misuse or who have medical complications associated with drug or alcohol dependency. Effective psychosocial approaches largely focus on brief, empirically tested manualised therapies such as cognitive therapy (Carroll, 1998a). However, modifications are required to such approaches to ensure that the interventions are tailored to the needs of clients exhibiting comorbidity. The data available demonstrate some evidence for the benefits of structured psychological approaches, but more sophisticated randomized controlled trials are required to evaluate the efficacy of both psychological and pharmacological approaches.

Substance use among schoolchildren in the north of England

A confidential and anonymous survey of 3623 adolescents was carried out in eight schools (six state comprehensive and two independent) in Newcastle upon Tyne. The survey enquired about cigarette use, alcohol consumption and illicit drug use together with key demographic variables. The results showed that 21% were currently smoking and 11% on a frequent basis. Regular smoking was more prevalent among girls. There was substantial use of alcohol, with 75% having used, and 20% drinking on a regular basis. This high level of alcohol consumption may be characteristic of northern Britain. The relatively low reported use of cannabis and relatively high reported use of naturally occurring hallucinogens may constitute a further regional variation. A minority of the sample (1.5%) were using illicit substances on a regular basis. Findings are discussed in terms of previous literature.